Investigating the appropriate adenosine deaminase cutoff value for the diagnosis of tuberculous pleural effusion in a country with decreasing TB burden

Conditional diagnostic accuracy according to inflammation status and age for diagnosing tuberculous effusion

BACKGROUND

Tuberculous effusion varies from lymphocyte-dominant to neutrophilic effusion according to inflammation status. The criteria of adenosine deaminase (ADA) and lymphocyte/neutrophil (L/N) ratio have yet not been evaluated across different disease conditions.

METHODS

Patients who conducted pleural fluid analysis from 2009 to 2019 at Asan Medical Center were included. Criteria (ADA of 50 and L/N ratio of 0.75) were evaluated by quantile subgroups according to age, C-reactive protein (CRP), white blood cell (WBC), and lactate dehydrogenase (LD) by the Monte Carlo simulation method to diagnose tuberculosis. The model for the ADA and L/N ratio was evaluated by AUROC.

RESULTS

Among the 2,918 reviewed cases, 2034 were included with 229 (11.26%) tuberculosis cases. The mean baseline ADA AUROC was 0.88 across all patients. Increased CRP and WBC showed high proportions of neutrophilic tuberculous effusion, with low sensitivity of approximately 45% and 33% in the fifth WBC and CRP groups, respectively. The AUROC of the models decreased with the increase in WBC and CRP groups (ADA model: 0.69 [the top quantile WBC group], 0.74 [the top quantile CRP group]). The AUROC of the models did not show a trend according to the increase in LD and age.

CONCLUSION

Inflammatory status affects the diagnostic metrics for tuberculous effusion due to the progression of tuberculous effusion. Clinicians should consider the low accuracy of tuberculous effusion criteria in high-inflammatory conditions when diagnosing tuberculosis.

Expert Review on Contemporary Management of Common Benign Pleural Effusions

Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.

Pulmonary tuberculosis among patients of tubercular pleural effusion: A single-center experience

Objective

To find out the prevalence of active pulmonary tuberculosis (TB) amongst patients of tubercular pleural effusion and to find out any direct association between tubercular pleural effusion and active pulmonary TB.

Methods

This was an observational study conducted in eastern India amongst patients of tubercular pleural effusion. Laboratory and radiological investigations were done for all of the patients. Patients with microbiological/radiological evidence of active pulmonary TB were classified as having primary disease. Rest of the patients were classified as having reactivated disease.

Results

A total of 50 patients were recruited in this study. Only 4 patients (8%) had radiological/microbiological evidence of active parenchymal TB. There was no difference in terms of demographic and laboratory features between patients with primary and reactivated disease.

Conclusion

Active pulmonary TB was found amongst a minority (4%) of cases of tubercular pleural effusion with reactivation of the past or, latent TB infection being responsible for the majority of the cases.