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Abstract
Pleural tuberculosis (TB) is common and often follows a benign course but may result in serious long-term morbidity. Diagnosis is challenging because of the paucibacillary nature of the condition. Advances in Mycobacterium culture media and PCR-based techniques have increased the yield from mycobacteriologic tests. Surrogate biomarkers perform well in diagnostic accuracy studies but must be interpreted in the context of the pretest probability in the individual patient. Confirming the diagnosis often requires biopsy, which may be acquired through thoracoscopy or image-guided closed pleural biopsy. Treatment is standard anti-TB therapy, with optional drainage and intrapleural fibrinolytics or surgery in complicated cases.
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Affiliation(s)
- Jane A Shaw
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa.
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, PO Box 241, Cape Town 8000, South Africa
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Shinohara T, Morizumi S, Sumitomo K. Varying clinical presentations of nontuberculous mycobacterial disease : Similar to but different from tuberculosis. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 68:220-227. [PMID: 34759134 DOI: 10.2152/jmi.68.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The incidence rate of pulmonary nontuberculous mycobacterial disease (PNTMD) in Japan is the highest among major industrialized nations. Although the typical clinical course and radiological manifestations of PNTMD are different from those of pulmonary tuberculosis (TB), confusion about these mycobacterial diseases leads to a diagnostic pitfall. Diagnostic challenges include the coexistence of Mycobacterium tuberculosis (MTB) and nontuberculous mycobacteria (NTM), false positives for NTM in MTB nucleic acid amplification tests, microbial substitution, and abnormal radiological manifestations caused by NTM. Features of extrapulmonary NTM diseases, such as pleurisy, vertebral osteomyelitis, and disseminated disease, are different from the corresponding tuberculous diseases. Moreover, the immunological background of the patient (status of human immunodeficiency virus infection with or without antiviral therapy, continuation or discontinuation of immunosuppressive therapy, use of immune checkpoint inhibitor, pregnancy and delivery, etc.) influences the pathophysiology of mycobacterial diseases. This review describes the varying clinical presentations of NTM disease with emphasis on the differences from TB. J. Med. Invest. 68 : 220-227, August, 2021.
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Affiliation(s)
- Tsutomu Shinohara
- Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan.,Department of Clinical Investigation, National Hospital Organization Kochi Hospital, Kochi, Japan
| | - Shun Morizumi
- Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan
| | - Kenya Sumitomo
- Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan
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53
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Thiagarajan D, Teh DAL, Ahmad Tarmidzi NA, Ishak H, Abu Bakar Z, Bastion MLC. Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression: a case report. Trop Dis Travel Med Vaccines 2021; 7:27. [PMID: 34649627 PMCID: PMC8516487 DOI: 10.1186/s40794-021-00153-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations. CASE PRESENTATION A 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery. CONCLUSION A high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.
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Affiliation(s)
- Dharshana Thiagarajan
- Department of Ophthalmology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia.
- Department of Ophthalmology, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
| | - Daphne Ai Lin Teh
- Department of Ophthalmology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Nor Azita Ahmad Tarmidzi
- Department of Ophthalmology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Hamisah Ishak
- Department of Ophthalmology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Zamzurina Abu Bakar
- Institute of Respiratory Medicine, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Mae-Lynn Catherine Bastion
- Department of Ophthalmology, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
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Yang G, Wen Y, Chen T, Xu C, Yuan M, Li Y. Comparison of pediatric empyema secondary to tuberculosis or non-tuberculosis community-acquired pneumonia in those who underwent surgery in high TB burden areas. Pediatr Pulmonol 2021; 56:3321-3331. [PMID: 34289260 DOI: 10.1002/ppul.25591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Tuberculous empyema (TE) in children is common in high-TB burden and medical resource-limited areas. However, studies that evaluate the characteristics of TE in children are sparse. This study aimed to analyze the clinical features of pediatric TE receiving surgical intervention. METHODS We performed a retrospective study of children with empyema secondary to community-acquired pneumonia who underwent surgery in our institution. The clinical characteristics were compared between TE and empyema secondary non-tuberculosis infection (non-tuberculosis empyema, NTE). RESULTS One hundred patients were included (27 with TE and 73 with NTE). Stage 3 empyema occupied 81.5% and 45.2% of TE and NTE in this study. The TE children had older age, longer duration of illness, and milder symptoms. Pleural fluid culture was positive for Mycobacterium tuberculosis in 7.4% of patients with TE. Lymph node enlargement, lymph node calcification, and pleural nodules presented in TE with high specificity (93.2%, 98.6%, and 98.5%) but low sensitivity (33.3%, 14.8%, and 29.6%) on CT scan. Thoracoscopy surgery was performed in 14 (51.9%) in TE and 39 (53.4%) in NTE. Postoperative chest-tube indwelling time was longer (7.85 ± 5.00 vs. 4.89 ± 1.81 days, p < .001), and more patients had incomplete lung expansion after 3 months in TE. CONCLUSION Tuberculosis infection should be screened in management of children with empyema in high-TB burden areas. Pediatric TE usually presented at older age and with milder respiratory symptoms. Pleural biopsy during surgery is often necessary to confirm the cause of infection. Thoracotomy is still required in some pediatric TE or NTE with delayed treatment in medical resource-limited area.
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Affiliation(s)
- Gang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Wen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ting Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Miao Yuan
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Laboratory of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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55
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Diagnosis of tuberculous pleural effusions: A review. Respir Med 2021; 188:106607. [PMID: 34536698 DOI: 10.1016/j.rmed.2021.106607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023]
Abstract
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
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Shi XY, Yi FS, Qiao X, Pei XB, Dong SF. Diagnostic accuracy of interleukin-33 for tuberculous pleural effusion: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26755. [PMID: 34397818 PMCID: PMC8341376 DOI: 10.1097/md.0000000000026755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The detection of interleukin 33 (IL-33) in pleural effusion may be more sensitive in diagnosing tuberculous pleural effusion (TPE). The present study aimed to assess the accuracy of pleural IL-33 for the diagnosis of TPE by means of meta-analysis and systematic review of relevant studies. METHOD After retrieving the published studies, the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and a summary receiver operating characteristic curve were assessed to estimate the usefulness of pleural IL-33 in diagnosing TPE using meta-analysis with a random-effects model. We also performed meta-regression and subgroup analysis. RESULTS A total of 639 patients from 6 studies were analyzed. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 0.87 (95% confidence interval [CI], 0.82-0.91), 0.76 (95% CI, 0.72-0.80), 6.54 (95% CI, 2.65-16.15), 0.17 (95% CI, 0.10-1.27), and 45.40 (95% CI, 12.83-160.70) respectively. The area under the curve was 0.94. The composition of the included population was the main cause of heterogeneity and subgroup analysis showed that pleural IL-33 had a higher specificity (0.93, 95% CI 0.87-0.96) when used for differential diagnosis between TPE and malignant pleural effusion. CONCLUSION The detection of IL-33 alone in pleural effusion seems to not be an efficient diagnostic marker for TPE but may serve as a novel biomarker to differentiate between TPE and malignant pleural effusion.
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Affiliation(s)
- Xin-Yu Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Feng-Shuang Yi
- Department of Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Qiao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xue-Bin Pei
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu-Feng Dong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Sakata K, Kikuchi J, Emoto K, Kotaki T, Ota Y, Nishina N, Hanaoka H, Otomo K, Suzuki K, Kaneko Y, Takeuchi T. Refractory IgG4-related Pleural Disease with Chylothorax: A Case Report and Literature Review. Intern Med 2021; 60:2135-2143. [PMID: 33518567 PMCID: PMC8313917 DOI: 10.2169/internalmedicine.6313-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We herein report a rare case of a 66-year-old man with refractory chylothorax. Although he had been treated with moderate doses of prednisolone (PSL) on suspicion of pleuritis with Sjögren syndrome, the pleural effusion expanded after the reduction of PSL. Further workup including histopathological examinations of pleura led to the diagnosis of IgG4-RD with bilateral chylothorax without any leakage from the thoracic duct. Combination therapy with high-dose PSL plus rituximab successfully decreased the pleural effusion. This is a very rare case of IgG4-related pleuritis with chylothorax and the first report of its successful treatment with rituximab.
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Affiliation(s)
- Komei Sakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Katsura Emoto
- Division of Diagnostic Pathology, Keio University School of Medicine, Japan
| | - Tomomi Kotaki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuichiro Ota
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Naoshi Nishina
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Kotaro Otomo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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Kumar Rai D, Thakur S. Study to identify incidence and risk factors associated Residual pleural opacity in tubercular pleural effusion. Indian J Tuberc 2021; 68:374-378. [PMID: 34099203 DOI: 10.1016/j.ijtb.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/09/2020] [Accepted: 12/29/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Residual pleural opacity (RPO) is a common radiographic sequela in patients with tubercular pleural effusion at the end of the treatment. This study was designed to find out the risk factors associated with residual pleural opacity (RPO). MATERIALS & METHODS This was a prospective longitudinal study performed to analyse data of 56 patients (46 males & 10 females) who were diagnosed as tubercular pleural effusion and treated for the same between 1st Jan 2019 to 30th March 2020. Chest X-ray posteroanterior & Lateral view was done (performed) at 0 and 6 months of treatment to quantify the amount of pleural effusion and measured the residual pleural opacity at the end of the treatment. RPO included both non resolving pleural effusion as well as residual pleural thickening (RPT). All statistical analysis was done using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Multivariate logistic regression was performed to explore the association of risk factors and Residual pleural opacity. The statistical significance level was set at 0.05 (two-tailed). RESULTS The incidence of Residual pleural opacity (RPO) at the end of 6 months of antituberculosis treatment was 53.57% (30/56)). The study patients were divided into RPO and non- RPO group. Male gender had significantly higher incidence of RPO (93.3% vs 69.2% P = 0.01)). Patients with RPO group had significantly more cough and weight loss as compared to non RPO group (96.6% vs 65.3% P = 0.002 and 60% vs 23% P = 0.005). The proportion of patients who underwent therapeutic aspiration and gained weight of more than 5kg during treatment (19.5% vs 7.6% P = 0.02 & 46.6% vs 7.6% P = 0.001) was significantly higher in RPO group. A significantly lower protein, glucose and higher LDH level in pleural fluid was observed in the RPO group compared to non-RPO group (P = 0.006, P = 0.01, P = 0.001)). No significant difference was found in the pleural fluid ADA, lymphocyte, neutrophil levels between the two groups (p > 0.05). Logistic regression analysis showed that the male gender, low pleural fluid glucose, presence of cough and weight loss were associated with significantly increased risk of residual pleural opacity and thickening (p < 0.05). CONCLUSION Tubercular pleural effusion is associated with residual pleural opacity in more than half of the patients. Male gender and low glucose levels in pleural fluid was associated with increased risk of residual pleural opacity.
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Affiliation(s)
| | - Somesh Thakur
- Department of Pulmonary Medicine, AIIMS, Patna, 801505, India
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Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance. JOURNAL OF RESPIRATION 2021. [DOI: 10.3390/jor1020015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.
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60
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Li X, Qin Y, Ye W, Chen X, Sun D, Guo X, Gu W. Diagnostic performance of D-dimer in predicting pulmonary embolism in tuberculous pleural effusion patients. BMC Pulm Med 2021; 21:177. [PMID: 34022828 PMCID: PMC8141242 DOI: 10.1186/s12890-021-01546-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 05/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background Tuberculous pleural effusion (TPE) patients usually have elevated D-dimer levels. The diagnostic performance of D-dimer in predicting pulmonary embolism (PE) in the TPE population is unclear. This study aimed to assess the diagnostic performance of D-dimer for PE in the TPE population and explore its potential mechanism. Methods We retrospectively analysed patients who were admitted to Xinhua Hospital and Weifang Respiratory Disease Hospital with confirmed TPE between March 2014 and January 2020. D-dimer levels were compared between patients with and without PE. To test the diagnostic performance of D-dimer in predicting PE, receiver operating characteristic curve analysis was performed. Positive predictive value (PPV) and negative predictive value (NPV) were also reported. To explore the potential mechanism of PE in TPE, inflammatory biomarkers were compared between PE and non-PE patients. Results This study included 248 patients (170 males and 78 females) aged 43 ± 20.6 years. Elevated D-dimer levels (≥ 0.5 mg/L) were detected in 186/248 (75%) patients. Of the 150 patients who underwent computed tomography pulmonary angiography, 29 were diagnosed with PE. Among the TPE population, the PE patients had significantly higher D-dimer levels than the non-PE patients (median, 1.06 mg/L vs. 0.84 mg/L, P < 0.05). The optimal cut-off value for D-dimer in predicting PE in TPE was 1.18 mg/L, with a sensitivity of 89.7% and a specificity of 77.8% (area under curve, 0.893; 95% confidence interval 0.839–0.947; P < 0.01). The PPV was 49.1%, while the NPV was 96.9% at a D-dimer cut-off of 1.18 mg/L for PE. PE patients had lower median WBC and interleukin (IL)-8 values (5.14 × 109/L vs. 6.1 × 109/L, P < 0.05; 30.2 pg/ml vs. 89.7 pg/ml, P < 0.05) but a higher median IL-2 receptor value (1964.8 pg/ml vs. 961.2 pg/ml, P < 0.01) than those in the non-PE patients. Conclusions D-dimer is an objective biomarker for predicting PE in patients with TPE. A D-dimer cut-off of 1.18 mg/L in the TPE population may reduce unnecessary radiological tests due to its excellent sensitivity, specificity, and NPV for PE. The imbalance of prothrombotic and antithrombotic cytokines may partly be attributed to the formation of pulmonary emboli in patients with TPE.
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Affiliation(s)
- Xiaoming Li
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092, China
| | - Yajing Qin
- Department of Respiratory and Critical Care Medicine, Weifang Respiratory Disease Hospital, Weifang NO.2 People's Hospital, 7, Yuanxiao Street, Weifang, 261041, Shandong Province, China
| | - Wenjing Ye
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092, China
| | - Xi Chen
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092, China
| | - Dezhi Sun
- Department of Respiratory and Critical Care Medicine, Weifang Respiratory Disease Hospital, Weifang NO.2 People's Hospital, 7, Yuanxiao Street, Weifang, 261041, Shandong Province, China
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092, China.
| | - Wen Gu
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665, Kongjiang Road, Shanghai, 200092, China.
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Yu S, Lao S, Yang B, Wu C. Tissue-Resident Memory-Like CD8 + T Cells Exhibit Heterogeneous Characteristics in Tuberculous Pleural Effusion. J Immunol Res 2021; 2021:6643808. [PMID: 33977110 PMCID: PMC8084674 DOI: 10.1155/2021/6643808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
Tissue-resident memory T (TRM) cells are well known to play critical roles in peripheral tissues during virus infection and tumor immunology. Our previous studies indicated that CD69+CD4+ and CD69+CD8+ T cells in tuberculous pleural effusion (TPE) were antigen-specific memory T cells. However, the phenotypical and functional characteristics of CD8+ TRM cells in tuberculosis remain unknown. We found that CD103+CD8+ T cells were the predominant subset of CD103+ lymphocytes in TPE; both CD103 and CD69 expressed on memory CD8+ T cells from TPE were significantly increased compared with those from paired peripheral blood. Phenotypically, CD103+CD69+ and CD103+CD69-CD8+ T cells expressed higher levels of CD45RO than CD103-CD69+CD8+ T cells did; CD103+CD69-CD8+ T cells highly expressed CD27, CD127, and CD62L and some chemokine receptors. We further compared the functional differences among the four distinct CD45RO+CD8+ T subsets identified by CD103 and CD69 expression. In consist with our published results, CD69+CD8+ T cells, but not CD103+CD8+, produced high levels of IFN-γ after treatment with BCG in the presence of BFA. Nevertheless, CD103-CD69+ and CD103+CD69+ memory CD8+ T cells expressed higher levels of Granzyme B, while CD103+CD69- memory CD8+ T cells were characterized as a possibly immunosuppressive subset by highly expressing CTLA-4, CD25, and FoxP3. Furthermore, TGF-β extremely increased CD103 expression but not CD69 in vitro. Together, CD103+CD8+ T cells form the predominant subset of CD103+ lymphocytes in TPE; CD103 and CD69 expression defines distinct CD8+ TRM-like subsets exhibiting phenotypical and functional heterogeneity. Our findings provide an important theoretical basis to optimize and evaluate new tuberculosis vaccines.
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Affiliation(s)
- Sifei Yu
- Institute of Immunology, Zhongshan School of Medicine, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510080, China
- Clinical Research Institute, The First People's Hospital of Foshan, 81 Lingnan Road, Foshan 528000, China
| | - Suihua Lao
- Chest Hospital of Guangzhou, 62 Hengzhigang Road, Guangzhou 510095, China
| | - Binyan Yang
- Institute of Immunology, Zhongshan School of Medicine, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Changyou Wu
- Institute of Immunology, Zhongshan School of Medicine, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510080, China
- Clifford Hospital, Jinan University, No. 3 Hongfu Road, Panyu, Guangzhou 511495, China
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Unstimulated Pleural Fluid Interferon Gamma for Diagnosis of Tuberculous Pleural Effusion: a Systematic Review and Meta-analysis. J Clin Microbiol 2021; 59:JCM.02112-20. [PMID: 33208475 DOI: 10.1128/jcm.02112-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Unstimulated interferon gamma may be a useful pleural fluid biomarker in the diagnosis of tuberculous pleural effusion (TPE). However, the exact threshold of pleural fluid interferon gamma and its accuracy during routine clinical decision-making is not clear. We assessed the performance of pleural fluid interferon gamma in diagnosing TPE and tried to identify a useful assay threshold. We queried the PubMed and Embase databases for publications indexed until May 2020 that provided both sensitivity and specificity data on unstimulated pleural fluid interferon gamma for diagnosis of TPE. A bivariate random effects model was employed to compute summary estimates for diagnostic accuracy parameters, both overall as well as at threshold ranges of <2, 2 to 5, and >5 IU/ml. We retrieved 2,048 citations, of which 67 publications (7,153 patients) were assessed in our review. The summary estimates for sensitivity, specificity, and diagnostic odds ratio were 0.93 (95% confidence interval [CI], 0.91 to 0.95), 0.96 (95% CI, 0.94 to 0.97), and 310.72 (95% CI, 185.24 to 521.18), respectively. Increasing interferon gamma thresholds did not translate into any substantial change in diagnostic performance; however, eight studies using thresholds of >5 IU/ml showed poorer diagnostic accuracy estimates than other studies with lower thresholds. None of the prespecified subgroup variables significantly influenced relative diagnostic odds ratios in a multivariate meta-regression model. All publications demonstrated a high risk of bias. Unstimulated pleural fluid interferon gamma level provides excellent accuracy for diagnosing TPE and has the potential of becoming a first-line test for this purpose.
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Gao S, Wang C, Yu X, Teng T, Shang Y, Jia J, Dong L, Zhao L, Liu S, Chu N, Huang H. Xpert MTB/RIF Ultra enhanced tuberculous pleurisy diagnosis for patients with unexplained exudative pleural effusion who underwent a pleural biopsy via thoracoscopy: A prospective cohort study. Int J Infect Dis 2021; 106:370-375. [PMID: 33845198 DOI: 10.1016/j.ijid.2021.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION To evaluate the performance of Xpert MTB/RIF Ultra (Xpert-Ultra) in testing pleural tissue and fluid collected by medical thoracoscopy among patients with unexplained exudative pleural effusion. METHODS Patients with an undiagnosed exudative pleural effusion were prospectively and consecutively recruited. Pleural tissue and fluid were collected by medical thoracoscopy and subjected to culture, Xpert MTB/RIF (Xpert) and Xpert-Ultra assays. Histopathological examination was also performed with the tissue and used as the major reference. RESULTS Sixty-one patients were enrolled, including: 27 tuberculosis (TB) pleurisy, 15 malignancy and 19 other chronic infection cases. The sensitivity, specificity, positive predictive value, and negative predictive value of Xpert-Ultra for TB diagnosis were 85.19% (23/27), 97.06% (33/34), 95.83% (23/24), and 89.19% (33/37), respectively. Xpert-Ultra testing with the biopsy tissue alone had an equivalent diagnostic capacity to that of pathological examination for the diagnosis of confirmed TB cases. By combining the pathological examination with Xpert-Ultra for biopsy, the percentage of confirmed TB cases greatly increased (i.e. 92.59% (25/27)). The "trace" positive outcome of Xpert-Ultra was highly supportive of TB diagnosis for both biopsy tissue and pleural fluid examinations. CONCLUSION With the specimens collected by medical thoracoscopy, the Xpert-Ultra assay presented high value in identifying TB among pleurisy patients who had difficulties in etiological diagnosis.
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Affiliation(s)
- Shan Gao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China; Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Chong Wang
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Xia Yu
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China
| | - Tianlu Teng
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China; Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Yuanyuan Shang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China; Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
| | - Junnan Jia
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China
| | - Lingling Dong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China
| | - Liping Zhao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China
| | - Shuku Liu
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China.
| | - Naihui Chu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China.
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing, China.
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Spener-Gomes R, Costa AG, Melo HFD, Souza ABD, Beraldi-Magalhães F, Jesus JS, Arriaga MB, Kritski A, Safe I, Andrade BB, Trajman A, Cordeiro-Santos M. Examination of respiratory specimens improves microbiological diagnosis of patients with presumptive extrapulmonary tuberculosis. Int J Infect Dis 2021; 105:743-745. [PMID: 33722683 PMCID: PMC8941595 DOI: 10.1016/j.ijid.2021.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Bacteriological confirmation of extrapulmonary tuberculosis (EPTB) is challenging for several reasons: the paucibacillary nature of the sample; scarce resources, mainly in middle and low-income countries; the need for hospitalization; and unfavorable outcomes. We evaluated the diagnostic role of respiratory specimen examination prospectively in a cohort of patients with presumptive EPTB. METHODS From July 2018 to January 2019, in a tuberculosis (TB)/HIV reference hospital, a cohort of 157 patients with presumed EPTB was evaluated. Xpert® MTB/RIF Ultra or a culture-positive result was considered for bacteriologically confirmed TB. RESULTS Out of 157 patients with presumptive EPTB, 97 (62%) provided extrapulmonary and respiratory specimens and 60 (38%) extrapulmonary specimens only. Of the 60 patients with extrapulmonary samples, 5 (8%) were positive. Of those with respiratory and extrapulmonary samples, 27 (28%) were positive: 10 in both the respiratory and extrapulmonary samples, 6 in the extrapulmonary sample only, and 11 in the respiratory sample only. A respiratory specimen examination increased by 6-fold the chance of bacteriological confirmation of TB (odds ratio = 5.97 [1.11-47.17]). CONCLUSION We conclude that respiratory samples should be examined in patients with presumptive EPTB.
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Affiliation(s)
- Renata Spener-Gomes
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil; Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil; Universidade Federal do Amazonas, Manaus, Brazil
| | - Allyson Guimarães Costa
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil; Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil; Universidade Federal do Amazonas, Manaus, Brazil; Fundação Hospitalar de Hematologia e Hemoterapia do Amazonas, Manaus, Brazil
| | - Hilda Ferreira de Melo
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil
| | - Alexandra Brito de Souza
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil; Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Francisco Beraldi-Magalhães
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil; Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil; Secretaria de Estado da Saúde do Paraná, Curitiba, Brazil; Faculdades Pequeno Príncipe, Curitiba, Brazil
| | | | - María B Arriaga
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Afrânio Kritski
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Izabella Safe
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Bruno B Andrade
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Anete Trajman
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil; Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; McGill International TB Centre, McGill University, Montreal, Canada
| | - Marcelo Cordeiro-Santos
- Programa de Pós-graduação em Medicina Tropical da Universidade do Estado do Amazonas, Manaus, Brazil; Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil; Universidade Nilton Lins, Manaus, Brazil.
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Biomarkers of Distinguishing Neutrophil-Predominant Tuberculous Pleural Effusion from Parapneumonic Pleural Effusion. Am J Med Sci 2021; 361:469-478. [PMID: 33781389 DOI: 10.1016/j.amjms.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/06/2020] [Accepted: 10/20/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tuberculous pleural effusion (TPE) is usually characterized by lymphocytic predominance and high pleural fluid adenosine deaminase (pfADA), while parapneumonic pleural effusion (PPE) is usually characterized by neutrophilic predominance. However, in some cases, neutrophils can be predominant in TPE. In such cases, the differential diagnosis between TPE and PPE is challenging and has been rarely investigated. The aim of this study was to evaluate the accuracy of pfADA, pleural fluid lactate dehydrogenase (pfLDH) and other parameters, such as age/pfADA in the differential diagnosis of neutrophil-predominant TPE (NP-TPE) and PPE. METHODS Between January 2003 and August 2018, 19 patients with NP-TPE and 54 patients with PPE at Shanghai Jiao Tong University Affiliated Sixth People's Hospital were retrospectively reviewed. Age, blood and pleural fluid findings, and eight ratios that consisted of routine biomarkers were compared between the two groups in ≤50 and >50 years old groups. ROC curve analysis was used to evaluate diagnostic performance. RESULTS The three parameters with the largest AUC were age/pfADA, pfADA and pfLDH in ≤ 50 years old group, and pfADA, age/pfADA and the percentage of neutrophils in pleural fluid (pfN%) in >50 years old group. For patients ≤ 50 years old, pfADA combined with pfLDH or age/pfADA combined with pfLDH could increase the specificity to 100%, while the sensitivity of the former was high (84.6% vs 76.9%). For patients >50 years old, both pfADA combined with pfN% and age/pfADA combined with pfN% could increase the specificity to 90.3% with the same sensitivity. CONCLUSIONS Although pfADA played an important role in the discrimination of NP-TPE from PPE, combining pfADA with pfLDH for patients ≤50 years old or combining pfADA with pfN% for patients >50 years old might improve diagnostic performance.
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Lei X, Wang J, Yang Z. Diagnostic Accuracy of Pleural Effusion Mononuclear Cells/Leukocyte Ratio in Tuberculous Pleurisy. Front Med (Lausanne) 2021; 8:639061. [PMID: 33816527 PMCID: PMC8012480 DOI: 10.3389/fmed.2021.639061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/24/2021] [Indexed: 01/15/2023] Open
Abstract
Background: Tuberculous pleurisy (TBP) is a common clinical type of tuberculosis (TB) in China. TBP is difficult to diagnose. Whether the mononuclear cell/leukocyte (MNC/LEU) ratio in pleural effusion can contribute to accurate TBP diagnosis remains yet unclear. Objective: To explore the diagnostic value of MNC/LEU ratio in pleural effusion for TBP in China. Methods: This study was a retrospective case-control study involving 406 patients with pleural effusion of unknown cause who were hospitalized at the Henan Provincial People's Hospital. Using histopathological examination of thoracoscopic pleural biopsy as the gold standard for TBP diagnosis, a final total of 215 subjects were included in this study including 91 cases of TBP and 124 cases of non-TBP. The receiver operating characteristic (ROC) curve of pleural effusion MNC/LEU ratio for TBP diagnosis was plotted and the area under curve (AUC) and the optimal cutoff value were determined. In addition, the sensitivity, specificity and accuracy of the MNC/LEU ratio at the optimal cutoff value for TBP diagnosis were also evaluated. Results: The MNC/LEU ratio was significantly higher in TB pleural effusion [95.9% (89.7–98.0%)] than in non-TB pleural effusion [77.8% (39.3–93.2%)] (P < 0.001). The AUC was 0.776 (95% CI, 0.714–0.830), and the sensitivity, specificity and accuracy for TBP diagnosis at the 93.7% cutoff value were 64.83%, 79.03%, and 0.730, respectively. Conclusion: The pleural effusion MNC/LEU ratio may be a new and valuable laboratory indicator for the diagnosis of tuberculous pleurisy in China.
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Affiliation(s)
- Xiaoli Lei
- Department of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, China
| | - Junli Wang
- Department of Cardiopulmonary Function, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Zhigang Yang
- Department of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, China
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Xpert MTB/RIF on pleural biopsy in suspected pleural TB: Does it add anything other than cost? Afr J Thorac Crit Care Med 2021; 27. [PMID: 34240038 PMCID: PMC8203050 DOI: 10.7196/ajtccm.2021.v27i1.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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[Predictive factors and biomarkers of exudative lymphocytic tuberculous pleurisy]. Rev Mal Respir 2021; 38:231-239. [PMID: 33531187 DOI: 10.1016/j.rmr.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 10/02/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Tuberculosis is the leading cause of exudative lymphocytic pleural effusion. OBJECTIVE To determine the predictive factors and assess the diagnostic performance of biomarkers for exudative lymphocytic tuberculous pleural effusion found in our practice. METHODS Case-control study from 01 January 2015 to 30 August 2019, including patients admitted to the day-hospital facility for pleural biopsy. Histopathology of pleural biopsy fragments was the gold standard for assessing the diagnostic performance of the biomarkers studied (pleural adenosine deaminase, geneXpert and pleural fluid culture). RESULTS One hundred and nine patients were included. The average age was 35.7±18.1 years. In all, 72.5% of them were diagnosed with tuberculosis. After multivariate analysis, only patients aged under 35 years old were found to be at risk for exudative lymphocytic tuberculous pleural effusion (adjusted odds ratio: 9.18 [1.99; 42.28], P=0.004). Histopathology was suggestive of tuberculosis in 84.8% of cases (P<0.0001). The sensitivity of geneXpert was 42.1% and the specificity was 100%, with a mean concordance rate with histopathology (k=0.46). One case of rifampicin-resistant tuberculosis was detected by geneXpert (2.2%). The diagnostic performance of pleural adenosine deaminase varies according to the defined positivity threshold. For values greater than 70UI/L, its sensitivity was 25% and its specificity was 86.7%. The area under the ROC curve of the pleural adenosine deaminase was 0.70. CONCLUSION In patients with exudative lymphocytic pleural effusion, young age is a risk factor for pleural tuberculosis. The geneXpert, although not very sensitive, is a moderately efficient and specific test for tuberculosis. Pleural adenosine deaminase is a discriminating and useful biomarker for the diagnosis of tuberculosis.
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Karagül DA, Barış VÖ, Karnak D. Additive effect of dabigatran and high-dose aspirin in the development of haemorrhagic pleural effusion in a patient with tuberculous pleuritis. Malawi Med J 2021; 32:176-179. [PMID: 33488990 PMCID: PMC7812147 DOI: 10.4314/mmj.v32i3.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Tuberculous pleuritis can rarely cause haemorrhagic pleural effusion. Dabigatran etexilate can have an additive effect on increasing the risk of haemorrhage. Aspirin cannot cause major haemorrhage, but in the elderly it can cause gastrointestinal bleeding via ulceration of the gastrointestinal mucosa. We report here the case of a 77-year-old male who presented to the hospital with a 2-month history of progressive dyspnoea. He had been taking dabigatran etexilate (220 mg) and high-dose acetylsalicylic acid (aspirin; 300 mg) daily for chronic atrial fibrillation. A chest X-ray revealed a moderately sized right pleural effusion confirmed by a computed tomography scan, which also showed bronchiectasis of both lungs. Dabigatran was discontinued and aspirin was decreased to the minimal therapeutic dose of 100 mg before thoracentesis was performed. Lymphocyte-predominant (50%) haemorrhagic fluid of 500 ml was drained, positive for acid-fast bacilli smear and polymerase chain reaction of Mycobacterium tuberculosis. A chest tube was placed and an additional 1250 ml of haemorrhagic exudate drained out. We treated the patient with a routine regimen of antituberculous medication and the infection resolved without complications other than the bronchiectasis present before treatment. We think that the combination of dabigatran etexilate and high doses of aspirin increased the risk of pleural haemorrhage in this patient with tuberculous pleuritis.
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Affiliation(s)
- Duygu Acar Karagül
- Chest Disease Department, Ankara University Medical Faculty, Ankara, Turkey
| | - Veysel Özgür Barış
- Cardiology Department, Ankara University Medical Faculty, Ankara, Turkey
| | - Demet Karnak
- Chest Disease Department, Ankara University Medical Faculty, Ankara, Turkey
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Beukes A, Shaw JA, Diacon AH, Irusen EM, Koegelenberg CFN. The Utility of Pleural Fluid Lactate Dehydrogenase to Adenosine Deaminase Ratio in Pleural Tuberculosis. Respiration 2020; 100:59-63. [PMID: 33333531 DOI: 10.1159/000509555] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/18/2020] [Indexed: 11/19/2022] Open
Abstract
In high-burden settings, the diagnosis of pleural tuberculosis (TB) is frequently inferred in patients who present with lymphocyte predominant exudative effusions and high adenosine deaminase (ADA) levels. Two recent small retrospective studies suggested that the lactate dehydrogenase (LDH)/ADA ratio is significantly lower in TB than in non-TB pleural effusions and that the LDH/ADA ratio may be useful in differentiating pleural TB from other pleural exudates. We compared the pleural LDH/ADA ratios, ADA levels, and lymphocyte predominance of a prospectively collected cohort of patients with proven pleural TB (n = 160) to those with a definitive alternative diagnosis (n = 68). The mean pleural fluid LDH/ADA ratio was lower in patients with pleural TB than alternative diagnoses (6.2 vs. 34.3, p < 0.001). The area under the receiver operating characteristic curve was 0.92 (p < 0.001) for LDH/ADA ratio and 0.88 (p < 0.001) for an ADA ≥40 U/L alone. A ratio of ≤12.5 had the best overall diagnostic efficiency, while a ratio of ≤10 had a specificity of 90% and a positive predictive value of 95%, with a sensitivity of 78%, making it a clinically useful "rule in" value for pleural TB in high incidence settings. When comparing the LDH/ADA ratio to an ADA level ≥40 U/L in the presence of a lymphocyte predominant effusion, the latter performed better. When lymphocyte values are unavailable, our data suggest that the LDH/ADA ratio is valuable in distinguishing TB effusions from other pleural exudates.
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Affiliation(s)
- Amanda Beukes
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jane Alexandra Shaw
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - Elvis M Irusen
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa,
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Huan NC, Khor IS, Ramarmuty HY, Lim MY, Ng KC, Syaripuddin A, Lee QZ, Teo WJ, Sivaraman Kannan KK. Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of tuberculous pleural effusion. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820978998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Pleural fluid adenosine deaminase (pfADA) is a simple, rapid and inexpensive surrogate marker for tuberculous pleural effusion (TPE). A nationwide cut-off of 40 U/L is currently used based on overseas data. There is a need to optimise the diagnostic utility of pfADA by establishing a local cut-off value. In this study, we aimed to describe the demographics and clinical characteristics of patients with TPE and non-TPE; determine the sensitivity and specificity of current pfADA of 40 U/L; and establish a new local pfADA cut-off for TPE. Methods: We conducted a single-centre, observational, prospective study of patients with exudative pleural effusion and pfADA measured from 1 October 2019 to 30 April 2020 at Queen Elizabeth Hospital, Malaysia. Results: The diagnosis of analysed patients ( n = 93) included TPE ( n = 41), malignancy ( n = 28), parapneumonic effusion ( n = 12) and other causes ( n = 12). The mean pfADA was 51.15 U/L (standard deviation (SD) = 13.77) among TPE group and 18.86 U/L (SD = 12.33) among non-TPE. When analysis was restricted to TPE patients, the local pfADA cut-off is 29.6 U/L, with a sensitivity of 97.6% and specificity of 90.4%. The current pfADA of 40 U/L has a sensitivity of 87.8% and specificity of 92.3%. Conclusion: We established a local pfADA cut-off of 29.6 U/L for TPE. Optimising the utility of pfADA helps to enhance clinicians’ treatment confidence of TPE when initial work-up is inconclusive.
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Affiliation(s)
- Nai-Chien Huan
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Inn Shih Khor
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Hema Yamini Ramarmuty
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Ming Yao Lim
- Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Kai Choon Ng
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Alfieyanto Syaripuddin
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Qin Zhi Lee
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Wee Jing Teo
- Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
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Tuberculous Pyopneumothorax as A Complication of Inadequate Treatment in Active Pulmonary Tuberculosis: A Case Report. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.2.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Predominance of Th1 Immune Response in Pleural Effusion of Patients with Tuberculosis among Other Exudative Etiologies. J Clin Microbiol 2019; 58:JCM.00927-19. [PMID: 31619524 DOI: 10.1128/jcm.00927-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 10/06/2019] [Indexed: 12/19/2022] Open
Abstract
Pleural tuberculosis (PlTB), a common form of extrapulmonary TB, remains a challenge in the diagnosis among many causes of pleural effusion. We recently reported that the combinatorial analysis of interferon gamma (IFN-γ), IFN-γ-inducible protein 10 (IP-10), and adenosine deaminase (ADA) from the pleural microenvironment was useful to distinguish pleural effusion caused by TB (microbiologically confirmed or not) among other etiologies. In this cross-sectional cohort study, a set of inflammatory mediators was quantified in blood and pleural fluid (PF) from exudative pleural effusion cases, including PlTB (n = 27) and non-PlTB (nTB) (n = 25) patients. The levels of interleukin-2 (IL-2), IL-4, IL-6, IL-10, IL-17A, IFN-γ, tumor necrosis factor (TNF), IP-10, transforming growth factor β1 (TGF-β), and ADA were determined using cytometric bead assay, enzyme-linked immunosorbent assay (ELISA), or biochemical tests. IFN-γ, IP-10, TNF, TGF-β, and ADA quantified in PF showed significantly higher concentrations in PlTB patients than in nTB patients. When blood and PF were compared, significantly higher concentrations of IL-6 and IL-10 in PF were identified in both groups. TGF-β, solely, showed significantly increased levels in PF and blood from PlTB patients when both clinical specimens were compared to those from nTB patients. Principal-component analysis (PCA) revealed a T helper type 1 (Th1) pattern attributed mainly to higher levels of IP-10, IFN-γ, TGF-β, and TNF in the pleural cavity, which was distinct between PlTB and nTB. In conclusion, our findings showed a predominantly cellular immune response in PF from TB cases, rather than other causes of exudative effusion commonly considered in the differential diagnosis of PlTB.
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Rapid Decline of IFN-γ Spot-Forming Cells in Pleural Lymphocytes during Treatment in a Patient with Suspected Tuberculosis Pleurisy. REPORTS 2019. [DOI: 10.3390/reports2040027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A differential diagnosis of tuberculosis pleurisy is often difficult. A 48-year-old Japanese man with no previous medical history visited the outpatient department for dyspnea and fever. His chest-XP and laboratory findings, especially high C-reactive protein levels, indicated pleuritis with pleural effusion. Pleural lymphocytes showed high numbers of spot forming responses in interferon gamma release assay (IGRA). Pleural effusion contained high levels of adenosine deaminase and hyaluronic acid, but no Mycobacterium tuberculosis (TB) antigen was detected by culture or polymerase chain reaction (PCR). Although the infectious agent was not detected, the clinical and laboratory findings strongly suggested that he was suffering from tuberculosis pleurisy. After treatment with anti-TB drugs, a rapid decline of spot-forming cells (SFCs) of pleural lymphocyte was observed, despite persistently high levels of other biomarkers and increased pleural lymphocytes. This case demonstrates that an IGRA of pleural lymphocytes would be useful for therapeutic diagnosis for TB pleurisy suspected for TB.
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