Corticosteroids and tuberculosis

Miliary pattern, a classic pulmonary finding of tuberculosis disease

Introduction

The increase in age of the population and in the use of immunosuppressive treatment makes tuberculosis (TB) with hematogenous or lymphatic dissemination a current problem.

Methods

We collected all the patients diagnosed with tuberculosis with miliary pulmonary pattern at the Santiago de Compostela University Teaching Hospital (NW Spain) from 1 January 2006 to 31 December 2015.

Results

A total of 27 patients were included, 70.4% women, with a median age of 69.0 years old. A cause of immunosuppression was observed only in 51.9% of patients. The majority of the cases (65.0%) presented pulmonary affectation. The most frequently isolated species was Mycobacterium tuberculosis (88.9%). Multiresistance to first-line antituberculosis drugs was observed only in 3.7%. 92.6% of the patients received treatment with Isoniazid, Rifampicin and Pyrazinamine, associated in 48.1% of them with Ethambutol. Two patients died during admission and there were no recurrences in the 2-years follow-up.

Conclusions

Miliary tuberculosis remains a current pathology. Most patients do not have a known cause of immunosuppression. The response to the typical treatment is usually good.

Interventions for treating tuberculous pericarditis

BACKGROUND

Tuberculous pericarditis can impair the heart's function and cause death; long term, it can cause the membrane to fibrose and constrict causing heart failure. In addition to antituberculous chemotherapy, treatments include corticosteroids, drainage, and surgery.

OBJECTIVES

To assess the effects of treatments for tuberculous pericarditis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register (27 March 2017); the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library (2017, Issue 2); MEDLINE (1966 to 27 March 2017); Embase (1974 to 27 March 2017); and LILACS (1982 to 27 March 2017). In addition we searched the metaRegister of Controlled Trials (mRCT) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal using 'tuberculosis' and 'pericard*' as search terms on 27 March 2017. We searched ClinicalTrials.gov and contacted researchers in the field of tuberculous pericarditis. This is a new version of the original 2002 review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search outputs, evaluated study eligibility, assessed risk of bias, and extracted data; and we resolved any discrepancies by discussion and consensus. One trial assessed the effects of both corticosteroid and Mycobacterium indicus pranii treatment in a two-by-two factorial design; we excluded data from the group that received both interventions. We conducted fixed-effect meta-analysis and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Seven trials met the inclusion criteria; all were from sub-Saharan Africa and included 1959 participants, with 1051/1959 (54%) HIV-positive. All trials evaluated corticosteroids and one each evaluated colchicine, M. indicus pranii immunotherapy, and open surgical drainage. Four trials (1841 participants) were at low risk of bias, and three trials (118 participants) were at high risk of bias.In people who are not infected with HIV, corticosteroids may reduce deaths from all causes (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.09; 660 participants, 4 trials, low certainty evidence) and the need for repeat pericardiocentesis (RR 0.85, 95% CI 0.70 to 1.04; 492 participants, 2 trials, low certainty evidence). Corticosteroids probably reduce deaths from pericarditis (RR 0.39, 95% CI 0.19 to 0.80; 660 participants, 4 trials, moderate certainty evidence). However, we do not know whether or not corticosteroids have an effect on constriction or cancer among HIV-negative people (very low certainty evidence).In people living with HIV, only 19.9% (203/1959) were on antiretroviral drugs. Corticosteroids may reduce constriction (RR 0.55, 0.26 to 1.16; 575 participants, 3 trials, low certainty evidence). It is uncertain whether corticosteroids have an effect on all-cause death or cancer (very low certainty evidence); and may have little or no effect on repeat pericardiocentesis (RR 1.02, 0.89 to 1.18; 517 participants, 2 trials, low certainty evidence).For colchicine among people living with HIV, we found one small trial (33 participants) which had insufficient data to make any conclusions about any effects on death or constrictive pericarditis.Irrespective of HIV status, due to very low certainty evidence from one trial, it is uncertain whether adding M. indicus pranii immunotherapy to antituberculous drugs has an effect on any outcome.Open surgical drainage for effusion may reduce repeat pericardiocentesis In HIV-negative people (RR 0.23, 95% CI 0.07 to 0.76; 122 participants, 1 trial, low certainty evidence) but may make little or no difference to other outcomes. We did not find an eligible trial that assessed the effects of open surgical drainage in people living with HIV.The review authors found no eligible trials that examined the length of antituberculous treatment needed nor the effects of other adjunctive treatments for tuberculous pericarditis.

AUTHORS' CONCLUSIONS

For HIV-negative patients, corticosteroids may reduce death. For HIV-positive patients not on antiretroviral drugs, corticosteroids may reduce constriction. For HIV-positive patients with good antiretroviral drug viral suppression, clinicians may consider the results from HIV-negative patients more relevant.Further research may help evaluate percutaneous drainage of the pericardium under local anaesthesia, the timing of pericardiectomy in tuberculous constrictive pericarditis, and new antibiotic regimens.

Tracheobronchial Tuberculosis Without Lung Involvement

Endotracheal tuberculosis (ETTB) is an infrequent form of tuberculosis whose major feature is the infection of the tracheobronchial tree by Mycobacterium tuberculosis. This case presents a 73-year-old man admitted to our hospital with fatigue, weakness, dry cough and weight loss. His chest X-ray was normal but the high resolution computed tomography (HRCT) showed normal parenchyma images with mediastinal and hilar lymphadenopathy. There was inflammation of the tracheal wall and infiltrates in pavement epithelium; however, the tracheal biopsy for acid-fast bacilli was negative. He was finally diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the lymph nodes. Four drugs were prescribed and symptoms improved. EBUS-TBNA contributed to prompt diagnosis. The patient was treated and evolved without complications, such as tracheal stenosis.

Challenges in endobronchial tuberculosis: from diagnosis to management

Despite the rapid advancement in diagnostic and therapeutic modalities, endobronchial tuberculosis (EBTB), defined as tuberculous infection of the tracheobronchial tree, continues to remain challenging for clinicians. Nonspecific respiratory symptoms along with normal chest radiograph in 10–20% of cases may be alleged for the diagnostic delay. Variable diagnostic yield with sputum microscopy might further compound the problem. In such cases, high resolution computed tomography (HRCT) works as a more sensitive tool and demonstrates involvement of tracheobronchial tree described classically as “tree-in-bud” appearance. Bronchoscopic biopsy is considered the most reliable method for confirmation of the diagnosis with 30% to 84% positivity in different series. Evolution of the disease is also unpredictable with frequent progression to bronchostenosis, therefore requiring regular follow-up and early intervention to halt the natural course. This review article elaborates various aspects of the disease with specific focus on diagnostic dilemma and recent advances in interventional bronchoscopy. In addition, this discussion evokes optimism for further research and introduction of innovative therapeutic modalities.

Flexible bronchoscopy for diagnosis and follow up of childhood endobronchial tuberculosis

BACKGROUND

In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB).

METHODS

Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study.

RESULTS

Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 +/- 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy.

CONCLUSIONS

Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Corticothérapie systémique et risque infectieux

PURPOSE

It was shown that corticosteroids alter the inflammatory and immune responses. Many publications report on serious infections occurring in patients receiving corticosteroids or presenting with Cushing's syndrome. This information is synthesized in this article.

CURRENT KNOWLEDGE AND KEY POINTS

The demonstration of the infectious risk associated with corticosteroids relies on observational data and on biological plausibility. However, this risk remains difficult to quantify, because of many confusing factors such as the patients' associated conditions and immunosuppressive treatments, and the highly variable dose and duration of the corticosteroid treatment. Taking into account the published data, the screening for a chronic infection seems licit among patients receiving a systemic corticosteroid treatment, in particular for those who will receive more than 10 mg of prednisone per day.

FUTURE PROSPECTS

Although no clinical trials of prevention of infections in corticosteroid treated patients has been published, a strategy aiming at minimizing the infectious risk of corticosteroid treated patients is proposed, based on the analysis of the literature presented in this article.

Tuberculosis in patients with systemic rheumatic or pulmonary diseases treated with glucocorticosteroids and the preventive role of isoniazid: a review of the available evidence

Development of tuberculosis (TB) is a concern in patients who receive glucocorticosteroids for the treatment of chronic rheumatic or pulmonary diseases. However, the incidence of development of TB in such patients and the prophylactic role of isoniazid (INH) are unclear. We evaluated the available evidence from 20 relevant prospective and retrospective cohort and case-control studies identified in the PubMed and Cochrane databases. The frequency of development of TB in the populations studied varied from 0% to 13.8%. This figure was low in studies performed in countries with a low incidence of TB (0% in the USA and Greece, 0.6% in France and 1.35% in Spain). In contrast, the frequency of development of TB in the studied cohorts was high in studies performed in countries with a moderate to high incidence of TB (from 2.5% in South Korea to 13.8% in The Philippines). Isoniazid prophylaxis (INHP) was found to decrease the incidence of development of TB in two of four studies that examined this intervention. The available evidence suggests that patients who receive steroids for the treatment of chronic rheumatic or pulmonary diseases and who live in countries with a high incidence of TB have a high risk of development of TB in contrast to patients who live in countries with a low incidence of the infection. However, the role of INHP even for patients living in countries where TB is endemic is unclear because the effectiveness of INH in preventing TB development in such patients is not well established and there are cost-effectiveness and safety issues.

Effect of corticosteroids on adult varicella pneumonia: cohort study and literature review

BACKGROUND

Varicella pneumonia (VP) is a serious entity associated with morbidity and mortality. There have been sporadic reports using corticosteroids in life-threatening VP. We report a case series of VP to examine the outcome and the effect of corticosteroid use.

METHODS

A retrospective chart review was conducted on all adult patients admitted to a tertiary care hospital with VP during a 14-year period. We documented oxygenation (SpO2, PaO2/FIO2) on admission and after 48 h, whether the patients were admitted to an intensive care unit (ICU), the use of mechanical ventilation, ICU and hospital length of stay (LOS) and patient outcome. We compared those patients who received corticosteroids with those who did not.

RESULTS

We identified 19 patients with VP. Ten received corticosteroids, in addition to antiviral and supportive treatment. Patients who received corticosteroids were significantly more hypoxaemic on admission and all were admitted to ICU with seven of them intubated. Only two of the nine in non-steroid group were intubated. Despite their greater severity, the corticosteroid group showed a much more rapid improvement in oxygenation and a trend towards shorter duration of mechanical ventilation. The duration of ICU and hospital LOS were not significantly different. All patients survived.

CONCLUSIONS

Corticosteroids in severe VP accelerate the physiological recovery and may shorten the duration of mechanical ventilation.

Bacterial pericarditis: diagnosis and management

Bacterial pericarditis occurs by direct infection during trauma, thoracic surgery, or catheter drainage, by spread from an intrathoracic, myocardial, or subdiaphragmatic focus, and by hematogenous dissemination. The frequent causes are Staphylococcus and Streptococcus (rheumatic pancarditis), Haemophilus, and M. tuberculosis. In AIDS pericarditis, the incidence of bacterial infection is much higher than in the general population, with a high proportion of Mycobacterium avium-intracellulare infection. Purulent pericarditis is the most serious manifestation of bacterial pericarditis, characterized by gross pus in the pericardium or microscopically purulent effusion. It is an acute, fulminant illness with fever in virtually all patients. Chest pain is uncommon. Purulent pericarditis is always fatal if untreated. The mortality rate in treated patients is 40%, and death is mostly due to cardiac tamponade, systemic toxicity, cardiac decompensation, and constriction. Tuberculous infection may present as acute pericarditis, cardiac tamponade, silent (often large) relapsing pericardial effusion, effusive-constrictive pericarditis, toxic symptoms with persistent fever, and acute, subacute, or chronic constriction. The mortality in untreated patients approaches 85%. Urgent pericardial drainage, combined with intravenous antibacterial therapy (e.g. vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, and ciprofloxacin 400 mg/day) is mandatory in purulent pericarditis. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable. The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day. Prednisone 1-2 mg/kg/day is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks. Drug sensitivity testing is essential. Pericardiectomy is reserved for recurrent effusions or continued elevation of central venous pressure after 4-6 weeks of antituberculous and corticosteroid therapy.

Endobronchial tuberculosis

Endobronchial tuberculosis is defined as tuberculous infection of the tracheobronchial tree. Although clinical features differ between various types and stages of endobronchial tuberculosis, common symptoms are cough, hemoptysis, sputum production, wheezing, chest pain, fever and dyspnea. Endobronchial tuberculosis is difficult to diagnose, because the lesion is not evident in the chest radiograph. Computerized tomography is very useful in evaluating bronchial lesions such as stenosis or obstruction. The most important goal of treatment in active endobronchial tuberculosis is the eradication of tubercle bacilli. The second most important goal is prevention of bronchial stenosis. Corticosteroid therapy for prevention of bronchial stenosis in endobronchial tuberculosis remains controversial, but the best results are associated with minimal delay in the initiation of steroid treatment. In inactive disease, treatment to restore full patency is appropriate. As steroids or other medication are unable to reverse stenosis from fibrous disease, airway patency must be restored mechanically by surgery or endobronchial intervention. Aerosol therapy with streptomycin and corticosteroids is useful in treatment against active endobronchial tuberculosis. Time to healing of ulcerous lesions is shorter, and bronchial stenosis is less severe in patients on aerosol therapy. Progression to bronchial stenosis may be prevented if the therapy is initiated as soon as possible.

Congenital tuberculosis requiring extracorporeal membrane oxygenation

We describe a 6-week-old infant with congenital tuberculosis with cardiorespiratory failure. She was successfully treated with ECMO initiated after worsening hypoxemia despite mechanical ventilation.

Varicella pneumonia: another 'steroid responsive' pneumonia?

Varicella-zoster virus (VZV) pneumonitis remains an often-fatal complication of VZV infection. Antiviral agents and supportive care are widely accepted therapies. Cautious use of corticosteroids in life-threatening VZV pneumonitis may be justified. Appropriate patient selection factors are as yet unidentified and the decision to commence corticosteroid therapy in this setting is clinical.

Interventions for treating tuberculous pericarditis

BACKGROUND

Tuberculous pericarditis - tuberculosis infection of the pericardial membrane (pericardium) covering the heart - is becoming more common. The infection can result in fluid around the heart or fibrosis of the pericardium, which can be fatal.

OBJECTIVES

In people with tuberculous pericarditis, to evaluate the effects on death, life-threatening conditions, and persistent disability of: (1) 6-month antituberculous drug regimens compared with regimens of 9 months or more; (2) corticosteroids; (3) pericardial drainage; and (4) pericardiectomy.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group trials register (June 2002), the Cochrane Controlled Trials Register (Issue 2, 2002), MEDLINE (1966 to June 2002), EMBASE (1980 to May 2002), and checked the reference lists of existing reviews. We also contacted organizations and individuals working in the field.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of treatments for tuberculous pericarditis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Meta-analysis using fixed effects models calculated summary statistics, provided there was no statistically significant heterogeneity, and expressed results as relative risk. Study authors were contacted for additional information.

MAIN RESULTS

Four trials met the inclusion criteria, with a total of 469 participants. Treatments tested were adjuvant steroids and surgical drainage. Two trials with a total of 383 participants tested adjuvant steroids in participants with suspected tuberculous pericarditis in the pre-HIV era. Fewer participants died in the intervention group, but numbers were small (relative risk [RR] 0.65; 95% confidence interval [CI] 0.36 to 1.16, n = 350). One small trial tested steroids in HIV positive participants with effusion showed a similar pattern (RR 0.50; 95% CI 0.19 to 1.28, n = 58). One trial examined open surgical drainage compared with conservative management, and showed surgery relieved cardiac tamponade.

REVIEWER'S CONCLUSIONS

Steroids could have important clinical benefits, but the trials published to date are too small to demonstrate an effect. This requires large placebo controlled trials. Subgroup analysis could explore whether effusion or fibrosis modify the effects. Therapeutic pericardiocentesis under local anaesthesia and pericardiectomy also require further evaluation.

Use of corticosteroids to suppress drug toxicity in complicated tuberculosis

Four cases of tuberculosis complicated by allergic or toxic reactions to antibiotic treatment are presented. In each, it was considered essential to suppress the reactions in order to give effective chemotherapy. This was achieved by using prednisolone generally in a dose of 40 mg/day or less during the continuation phase of therapy. Reactions to essential treatment are an important indication for corticosteroid treatment in tuberculosis.

Corticosteroids in life-threatening varicella pneumonia

BACKGROUND

Varicella pneumonia that results in respiratory failure or progresses to the institution of mechanical ventilation carries a significant morbidity and mortality despite intensive respiratory support and antiviral therapy. There has been no reported study of the role of corticosteroids in life-threatening varicella pneumonia.

DESIGN AND METHODS

This was an uncontrolled retrospective and prospective study of all adult patients with a diagnosis of varicella pneumonia who were admitted to the ICUs of the Johannesburg group of academic hospitals in South Africa between 1980 and 1996. Patient demographics, clinical and laboratory features, necessity for mechanical ventilation, and complications were reviewed. The outcome and therapy of varicella pneumonia was evaluated with particular reference to the use of corticosteroids. Patients with comorbid disease and those already taking immunosuppressive agents were excluded. Key endpoints included length of ICU and hospital stay and mortality.

MEASUREMENTS AND RESULTS

Fifteen adult patients were evaluated, six of whom received corticosteroids in addition to antiviral and supportive therapy. These six patients demonstrated a clinically significant therapeutic response. They had significantly shorter hospital (median difference, 10 days; p<0.006) and ICU (median difference, 8 days; p=0.008) stays and there was no mortality, despite the fact that they were admitted to the ICU with significantly lower median ratios between PaO2 and fraction of inspired oxygen than those patients (n=9) who did not receive corticosteroid therapy (86.5 vs 129.5; p=0.045).

CONCLUSION

When used in addition to appropriate supportive care and early institution of antiviral therapy, corticosteroids appear to be of value in the treatment of previously well patients with life-threatening varicella pneumonia. The observations presented in this study are important and should form the basis for a randomized controlled trial, as no other relevant studies or guidelines are available.

Systemic corticosteroid therapy--side effects and their management

The anti-inflammatory effects of corticosteroids cannot be separated from their metabolic effects as all cells use the same glucocorticoid receptor; therefore when corticosteroids are prescribed measures should be taken to minimise their side effects. Clearly, the chance of significant side effects increases with the dose and duration of treatment and so the minimum dose necessary to control the disease should be given. Before embarking on a long term course of corticosteroids the factors summarised in Table 1 should be considered. A full discussion with the patient is necessary in order to explain the benefits and risks of corticosteroid treatment. A patient information leaflet is now provided by the manufacturers of all systemic corticosteroid preparations. As emphasised by the recent publication by the Committee on the Safety of Medicines, advice to patients is the key to the safe use of long term systemic corticosteroids and it recommends discussing the following points with the patient: not to stop taking corticosteroids suddenly to see a doctor if they become unwell of the increased susceptibility to infections, especially chickenpox of the serious side effects that may occur to read and keep the patient information leaflet to always carry the steroid treatment card and to show it to any health professional involved in their treatment. In addition the following suggestions may help to minimise some side effects: a single morning dose early dietary modification--low calorie, low sodium, and high potassium awareness of possible errors of judgment on high doses. Once started on corticosteroids the patient should be regularly reviewed to assess the response to the treatment with adjustments to keep the dose at a minimum.

Airway stenosis after tracheo-bronchial tuberculosis

Primary endobronchial localization of tuberculosis without change on chest X-ray is a rare clinical entity, and bronchoscopic examination is most appropriate to reveal such an occurrence. A 38-year-old man and a 52-year-old woman underwent fibre-optic bronchoscopy many months after the onset of cough with poor sputum and dyspnoea on exercise, chest X-ray being normal. In both cases, a widespread granulomatous involvement of the tracheo-bronchial tree was found and cultures of bronchial wash grew Mycobacterium tuberculosis. Patients recovered after 6 months of combined anti-tuberculous and steroid therapy; the granulomatous lesions disappeared but stenoses were found in the trachea and/or main bronchi. In one case, CO2 laser therapy was performed with no improvement.

Tuberculous meningitis in immunocompetent adults: two cases with a clinico-radiological discussion

In developed countries with a low incidence of tuberculosis, infection with Mycobacterium tuberculosis is easily overlooked as the cause of meningitis in an immunocompetent adult. Two cases are presented, with emphasis on the main reasons for delay of diagnosis. Neuroradiology revealed a progressive hypertrophic basal meningitis. The clinical and radiological outcome was good after tuberculostatic and corticosteroid treatment.

Study of paradoxical response to chemotherapy in tuberculous pleural effusion

BACKGROUND

Paradoxical worsening of disease, in spite of effective chemotherapy for tuberculosis, has been reported to occur in cases of intracranial tuberculoma, lymph node, and pulmonary tuberculosis. However, only rare case reports describe such paradoxical response in tuberculosis pleurisy.

METHODS

Sixty-one patients with proven tuberculous pleural effusion were retrospectively screened in Riyadh, Saudi Arabia, in three major hospitals to look systematically at the incidence and features of paradoxical response.

RESULTS

Paradoxical increase in the size of the effusion was detected in 10 of 61 patients. In six patients, the effusion became massive with worsening of dyspnoea requiring the use of corticosteroids in five patients and therapeutic aspiration in all six. However, complete resolution occurred in all 10 patients within 1-3 months. Three out of the 10 patients developed residual pleural thickening.

CONCLUSION

An incidence of 16% (10/61) paradoxical worsening of tuberculous effusion following the start of anti-tuberculous treatment has been documented. This resulted in respiratory distress necessitating therapeutic re-aspiration in six of 10 patients.

Randomised trial of corticosteroids in the treatment of tuberculous pleurisy

BACKGROUND

Tuberculous pleurisy can result in pleural fibrosis, calcification and thickening. To prevent these complications, corticosteroids are frequently used in addition to antituberculous drugs; however, new therapeutic regimens can control the disease and minimise the sequelae, and there is no convincing evidence of the benefit of the use of corticosteroids as adjuvant therapy.

METHODS

Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Additionally, they were randomly assigned to a double blind treatment with either prednisone (1 mg/kg/day for 15 days and then tapering off) or placebo during the first month of treatment. Different clinical, radiological, and functional parameters were evaluated to assess the effect of corticosteroids.

RESULTS

Fifty seven patients received prednisone and 60 placebo. At the end of the treatment the clinical outcome, the rate of reabsorption of the pleural fluid, the pleural sequelae, as well as lung capacity were similar in both groups.

CONCLUSIONS

Corticosteroids do not influence the clinical outcome or the development of long term pleural sequelae in tuberculous pleurisy.