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Ajibola OA, Happel KI. Early Use of Intrapleural Tissue Plasminogen Activator and Dornase Alfa in Loculated Pleural Effusion Due to Mycobacterium Tuberculosis. Cureus 2023; 15:e49125. [PMID: 38125208 PMCID: PMC10732475 DOI: 10.7759/cureus.49125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Tuberculosis is a highly infectious respiratory disease due to Mycobacterium tuberculosis (MTb). The most common manifestation of MTb is pulmonary tuberculosis, but some patients can present with extrapulmonary manifestations as their initial presentation. Tuberculous pleurisy and pleural effusion are among the most common extrapulmonary manifestations of MTb. The treatment of pleural MTb is the same as the treatment for pulmonary disease, with a four-drug regimen with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) under directly observed therapy (DOT). Drainage of the pleural effusion is usually not recommended in tuberculosis pleural effusion. We present a case of a complex, loculated pleural effusion due to MTb in an otherwise healthy middle-aged male who responded rapidly and completely to an early, short course of intrapleural tissue plasminogen activator and dornase alfa (TPA/DNase) therapy.
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Affiliation(s)
- Oluwafemi A Ajibola
- Pulmonary and Critical Care Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Kyle I Happel
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
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Clinical Worsening in an Adolescent With Pleural Tuberculosis. J Adolesc Health 2023; 72:480-482. [PMID: 36567181 DOI: 10.1016/j.jadohealth.2022.11.013] [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: 07/23/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
A 17-year-old previously healthy female presented with unilateral chest pain and dyspnea. Chest radiographs demonstrated a unilateral pleural effusion and pneumonia. Pleural fluid bacterial cultures were negative; acid-fast cultures grew Mycobacterium tuberculosis. Two months after starting appropriate therapy, she had a recrudescence of symptoms and reaccumulation of the pleural fluid. Her tuberculosis antibiotic regimen was expanded, the effusion drained, and systemic corticosteroids initiated, resulting in rapid clinical improvement. Cultures of the second pleural fluid collection were negative. Her clinical deterioration was due to immune reconstitution inflammatory syndrome (IRIS). IRIS can be seen within the first several months of starting tuberculosis therapy and can result in paradoxical worsening of symptoms or radiographic findings in adolescents who are on the appropriate therapy. IRIS is a diagnosis of exclusion after drug resistance and medication malabsorption, intolerance, and nonadherence are excluded. Therapy includes nonsteroidal anti-inflammatory agents for milder reactions and systemic corticosteroids for more severe IRIS cases.
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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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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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Fitzgerald DB, Waterer GW, Read CA, Fysh ET, Shrestha R, Stanley C, Muruganandan S, Lan NSH, Popowicz ND, Peddle-McIntyre CJ, Rahman NM, Gan SK, Murray K, Lee YCG. Steroid therapy and outcome of parapneumonic pleural effusions (STOPPE): Study protocol for a multicenter, double-blinded, placebo-controlled randomized clinical trial. Medicine (Baltimore) 2019; 98:e17397. [PMID: 31651842 PMCID: PMC6824804 DOI: 10.1097/md.0000000000017397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a major global disease. Parapneumonic effusions often complicate CAP and range from uninfected (simple) to infected (complicated) parapneumonic effusions and empyema (pus). CAP patients who have a pleural effusion at presentation are more likely to require hospitalization, have a longer length of stay and higher mortality than those without an effusion. Conventional management of pleural infection, with antibiotics and chest tube drainage, fails in about 30% of cases. Several randomized controlled trials (RCT) have evaluated the use of corticosteroids in CAP and demonstrated some potential benefits. Importantly, steroid use in pneumonia has an acceptable safety profile with no adverse impact on mortality. A RCT focused on pediatric patients with pneumonia and a parapneumonic effusion demonstrated shorter time to recovery. The effects of corticosteroid use on clinical outcomes in adults with parapneumonic effusions have not been tested. We hypothesize that parapneumonic effusions develop from an exaggerated pleural inflammatory response. Treatment with systemic steroids may dampen the inflammation and lead to improved clinical outcomes. The steroid therapy and outcome of parapneumonic pleural effusions (STOPPE) trial will assess the efficacy and safety of systemic corticosteroid as an adjunct therapy in adult patients with CAP and pleural effusions. METHODS STOPPE is a pilot multicenter, double-blinded, placebo-controlled RCT that will randomize 80 patients with parapneumonic effusions (2:1) to intravenous dexamethasone or placebo, administered twice daily for 48 hours. This exploratory study will capture a wide range of clinically relevant endpoints which have been used in clinical trials of pneumonia and/or pleural infection; including, but not limited to: time to clinical stability, inflammatory markers, quality of life, length of hospital stay, proportion of patients requiring escalation of care (thoracostomy or thoracoscopy), and mortality. Safety will be assessed by monitoring for the incidence of adverse events during the study. DISCUSSION STOPPE is the first trial to assess the efficacy and safety profile of systemic corticosteroids in adults with CAP and pleural effusions. This will inform future studies on feasibility and appropriate trial endpoints. TRIAL REGISTRATION ACTRN12618000947202 PROTOCOL VERSION:: version 3.00/26.07.18.
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Affiliation(s)
- Deirdre B. Fitzgerald
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
| | - Grant W. Waterer
- Medical School, Faculty of Health & Medical Sciences
- Respiratory Medicine, Royal Perth Hospital
| | - Catherine A. Read
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
| | | | | | | | | | | | - Natalia D. Popowicz
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
- School of Allied Health, University of Western Australia
| | - Carolyn J. Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health
- School of Medical and Health Sciences, Edith Cowan University
| | | | - Seng Khee Gan
- Medical School, Faculty of Health & Medical Sciences
- Endocrinology and Diabetes, Royal Perth Hospital, Perth
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Western Australia, Australia
| | - Yun Chor Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
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Shaw JA, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusion. Respirology 2019; 24:962-971. [PMID: 31418985 DOI: 10.1111/resp.13673] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Abstract
Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.
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Affiliation(s)
- Jane A Shaw
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
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Antonangelo L, Faria CS, Sales RK. Tuberculous pleural effusion: diagnosis & management. Expert Rev Respir Med 2019; 13:747-759. [PMID: 31246102 DOI: 10.1080/17476348.2019.1637737] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Background: Tuberculosis (TB) is the world's leading cause of death from infectious disease. The World Health Organization (WHO) recognized 6.3 million new TB cases in 2017, 16% corresponding to extrapulmonary forms; pleural tuberculosis (PT) is the most common extrapulmonary form in adults. PT diagnosis is often challenging because the scarcity of bacilli in pleural fluid (PF), sometimes requiring invasive procedures to obtain pleural tissue for histological, microbiological or molecular examination. In regions of medium and high disease prevalence, adenosine deaminase (ADA), interferon gamma (IFN-γ) and interleukin 27 (IL-27) dosages are useful to establish presumptive diagnosis in patients with compatible clinical/radiological picture who present with lymphocytic pleural effusion. PT treatment is similar to the pulmonary TB treatment regimen recommended by WHO. Area covered: In this update, we present a PT review, including epidemiology, pathogenesis, clinical features, diagnosis, and therapy. Expert opinion: There is no PF test alone accurate for PT diagnosis, despite the evolution in clinical laboratory. ADA, IFN-γ and IL-27 are valuable laboratory biomarkers; however, IFN-γ and IL-27 are quite expensive. Molecular tests present low sensitivity in PF, being useful for diagnostic confirmation. Multidrug therapy remains the PT treatment choice. Advancing research in immunotherapy may bring benefits to PT patients.
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Affiliation(s)
- Leila Antonangelo
- a Divisao de Patologia Clinica - Departamento de Patologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo , Sao Paulo , BR.,b Laboratorio de Investigacao Medica - LIM 03, Faculdade de Medicina, Universidade de Sao Paulo , Sao Paulo , BR
| | - Caroline S Faria
- b Laboratorio de Investigacao Medica - LIM 03, Faculdade de Medicina, Universidade de Sao Paulo , Sao Paulo , BR
| | - Roberta K Sales
- c Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo , Sao Paulo , BR
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Abstract
PURPOSE OF REVIEW Pleural infection remains an important pulmonary disease, causing significant morbidity and mortality. There is a resurgence of disease burden despite introduction of antibiotics and pneumococcal vaccines. A revisit of the pathogenesis and update on intervention may improve the care of pleural infection. RECENT FINDINGS Recent studies have uncovered the prognostic implication of the presence of a pleural effusion in patients with pneumonia. Identifying where the bacteria lives may have diagnostic and therapeutic implications. Over-exaggerated pleural inflammation may underlie development of parapneumonic effusion as indirect evidence and a randomized study in children raised a role of corticosteroids in parapneumonic pleural effusions, but data are lacking for adults. Optimization of the delivery regimen of intrapleural fibrinolytic and deoxyribonuclease therapy is ongoing. SUMMARY The review aims to review the current practice and explore new directions of treatment on pleural infection.
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Schutz C, Davis AG, Sossen B, Lai RPJ, Ntsekhe M, Harley YXR, Wilkinson RJ. Corticosteroids as an adjunct to tuberculosis therapy. Expert Rev Respir Med 2018; 12:881-891. [PMID: 30138039 PMCID: PMC6293474 DOI: 10.1080/17476348.2018.1515628] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Inflammation, or the prolonged resolution of inflammation, contributes to death from tuberculosis. Interest in inflammatory mechanisms and the prospect of beneficial immune modulation as an adjunct to antibacterial therapy has revived and the concept of host directed therapies has been advanced. Such renewed attention has however, overlooked the experience of such therapy with corticosteroids. Areas covered: The authors conducted literature searches and evaluated randomized clinical trials, systematic reviews and current guidelines and summarize these findings. They found evidence of benefit in meningeal and pericardial tuberculosis in HIV-1 uninfected persons, but less so in those HIV-1 coinfected and evidence of harm in the form of opportunist malignancy in those not prescribed antiretroviral therapy. Adjunctive corticosteroids are however of benefit in the treatment and prevention of paradoxical HIV-tuberculosis immune reconstitution inflammatory syndrome. Expert commentary: Further high-quality clinical trials and experimental medicine studies are warranted and analysis of materials arising from such studies could illuminate ways to improve corticosteroid efficacy or identify novel pathways for more specific intervention.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Angharad G Davis
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom
- University College London, United Kingdom
| | - Bianca Sossen
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Rachel P-J Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom
- Department of Medicine, Imperial College London W2 1PG, United Kingdom
| | - Mpiko Ntsekhe
- Division of Cardiology, Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Yolande XR Harley
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom
- University College London, United Kingdom
- Department of Medicine, Imperial College London W2 1PG, United Kingdom
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Sun F, Li L, Liao X, Yan X, Han R, Lei W, Cao H, Feng M, Cao G. Adjunctive use of prednisolone in the treatment of free-flowing tuberculous pleural effusion: A retrospective cohort study. Respir Med 2018; 139:86-90. [PMID: 29858007 DOI: 10.1016/j.rmed.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/14/2018] [Accepted: 05/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adjunctive use of corticosteroids with anti-tuberculosis (TB) therapy has been reported to benefit people with tuberculous pleural effusion (TPE), while there is a paucity of data to support it as routine use. TPE can be subdivided into free-flowing type and loculated type. We evaluated the effects of adjunctive prednisolone therapy on functional sequelae, pleural thickening and pleural adhesions in patients with free-flowing TPE. METHODS This is a retrospective cohort study, conducted from Jan 2013 to Dec 2016 (ChiCTR-ORC-16009267). All the patients were diagnosed with TPE, and treated with standard 4-drug anti-TB chemotherapy regimen and complete drainage of the effusion. We compared the incidence of a composite of roentgenographic sequelae (pleural thickening of > 2 mm, or pleural adhesions and costophrenic angle > 90°), or restrictive functional sequelae (FVC/FVC pre or TLC/TLC pre < 80%) between those who received adjunctive prednisolone therapy and those who did not. RESULTS The final cohorts consisted of 135 subjects. Of those, 56 received adjunctive prednisolone therapy and 79 did not. The incidence of a composite of roentgenographic sequelae or restrictive functional sequelae was significantly decreased in the prednisolone group as compared with the control group (51.8% vs. 75.9%; RR 2.83, 95% confidence interval, 1.27-6.31, P = 0.011). No serious side effects due to corticosteroid were noted. CONCLUSIONS This study detected a significant association between adjunctive prednisolone therapy and decreased incidence of a composite of radiographic sequelae, or functional sequelae in HIV-negative, free-flowing type TPE patients treated with adjunctive prednisolone.
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Affiliation(s)
- Fenfen Sun
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Li Li
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xiuqing Liao
- Department of Respiratory Disease, Fuling Center Hospital of Chongqing City, Chongqing, China
| | - Xiaofeng Yan
- Chongqing Infectious Disease Medical Center, Chongqing, China
| | - Rui Han
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Wenhui Lei
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Hui Cao
- Department of Radiology, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Mingxia Feng
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Guoqiang Cao
- Department of Respiratory Disease, Daping Hospital, Third Military Medical University, Chongqing, China.
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Komissarov AA, Rahman N, Lee YCG, Florova G, Shetty S, Idell R, Ikebe M, Das K, Tucker TA, Idell S. Fibrin turnover and pleural organization: bench to bedside. Am J Physiol Lung Cell Mol Physiol 2018; 314:L757-L768. [PMID: 29345198 DOI: 10.1152/ajplung.00501.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.
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Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Najib Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital; and National Institute of Health Research Biomedical Research Centre , Oxford , United Kingdom
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital; Pleural Medicine Unit, Institute for Respiratory Health , Perth ; School of Medicine and Pharmacology, University of Western Australia , Perth , Australia
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Sreerama Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Richard Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Mitsuo Ikebe
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Kumuda Das
- Department of Translational and Vascular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Torry A Tucker
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
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Xie S, Lu L, Li M, Xiong M, Zhou S, Zhang G, Peng A, Wang C. The efficacy and safety of adjunctive corticosteroids in the treatment of tuberculous pleurisy: a systematic review and meta-analysis. Oncotarget 2017; 8:83315-83322. [PMID: 29137345 PMCID: PMC5669971 DOI: 10.18632/oncotarget.18160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 03/09/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of adjunctive corticosteroids in the treatment of patients with tuberculous pleurisy. Methods The PubMed, Cochrane, Medline, Embase, Web of Science and Chinese National Knowledge Infrastructure were searched. Clinical trials of corticosteroids compared with control were eligible for inclusion. Results Ten studies (6 randomized controlled trials [RCTs] and 4 non-RCTs) with 957 participants met the inclusion criteria. Compared to the controls (placebos or non-steroids), adjunctive corticosteroid use reduced the risk of residual pleural fluid after 4 weeks and the number of days to symptom improvement; however, there was no convincing evidence to support the positive effects of corticosteroids over the long term (8 weeks) on residual pleural fluid, pleural thickening, or pleural adhesions, and there was no statistical difference between the corticosteroid group and control group with respect to 7-days relief of the clinical symptoms or death from any cause. In addition, more adverse events were observed in patients who received corticosteroids than in those in the control group. Conclusions Our results suggest that adjunctive corticosteroid use did not improve long-term efficacy and might induce more adverse events, although the risk of residual pleural fluid at 4 weeks and the number of days to symptom improvement were reduced.
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Affiliation(s)
- Shuanshuan Xie
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Lin Lu
- Department of Nephrology, North Huashan Hospital, Fudan University, Shanghai, China
| | - Ming Li
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Mengting Xiong
- Department of Cardiology Medicine, Pudong Hospital, Fudan University, Shanghai, China
| | - Shunping Zhou
- Department of Cardiology Medicine, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoliang Zhang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Aimei Peng
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Changhui Wang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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Abstract
BACKGROUND Corticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent and raise doubt as to whether such treatment is worthwhile. There is also concern regarding the potential adverse effects of corticosteroids, especially in HIV-positive people. OBJECTIVES To evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion. SEARCH METHODS In April 2016, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, LILACS, Current Controlled Trials, and the reference lists of articles identified by the literature search. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs that compared any corticosteroid with no treatment, placebo, or other active treatment (both groups should have received the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, extracted data from the included trials, and assessed trial methodological quality using the Cochrane 'Risk of bias' tool. We analysed the data using risk ratios (RR) with 95% confidence intervals (CIs). We applied the fixed-effect model in the absence of statistically significant heterogeneity. MAIN RESULTS Six trials with 590 participants met the inclusion criteria, which were conducted in Asia (three trials), Africa (two trials), and Europe (one trial). Two trials were in HIV-negative people, one trial was in HIV-positive people, and three trials did not report HIV status.Corticosteroids may reduce the time to resolution of pleural effusion. Risk of residual pleural effusion on chest X-ray was reduced by 45% at eight weeks (RR 0.54, 95% CI 0.37 to 0.78; 237 participants, 2 trials, low certainty evidence), and 65% at 24 weeks (RR 0.35, 95% CI 0.18 to 0.66; 237 participants, 2 trials, low certainty evidence).Compared with control, corticosteroids may reduce the risk of having pleural changes (such as pleural thickening or pleural adhesions), on chest X-ray at the end of follow-up by almost one third (RR 0.72, 95% CI 0.57 to 0.92; 393 participants, 5 trials,low certainty evidence), which translates to an absolute risk reduction of 16%.One trial reported deaths in people that were HIV-positive, with no obvious difference between the groups; the trial authors' analysis suggests that the deaths observed in this trial were related to HIV disease rather than pleural TB (RR 0.91, 95% CI 0.64 to 1.31; 197 participants, 1 trial).We found limited data on long-term functional respiratory impairment on 187 people in two trials, which reported that average percentage predicted forced vital capacity was similar in the group receiving prednisolone and in the control group (very low certainty evidence).The risk of adverse events that led to discontinuation of the trial drug was higher in people with pleural TB receiving corticosteroids (RR 2.78, 95% CI 1.11 to 6.94; 587 participants, 6 trials, low certainty evidence). The trial in HIV-positive people reported on six different HIV-related infections, with no obvious differences. However, cases of Kaposi's sarcoma were only seen in the corticosteroid group (with 6/99 cases in the steroid group compared to 0/98 in the control group) (very low certainty evidence). AUTHORS' CONCLUSIONS Long-term respiratory function is potentially the most important outcome for assessing the effects of adjunctive treatments for people with pleural TB. However, the information on the impact of pleural TB on long-term respiratory function is unknown and could be eclipsed by other risk factors, such as concurrent pulmonary TB, smoking, and HIV. This probably needs to be quantified to help decide whether further trials of corticosteroids for pleural TB would be worthwhile.
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Affiliation(s)
- Hannah Ryan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Jinho Yoo
- Kyung Hee UniversitySeoulKorea, South
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 680] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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Abstract
PURPOSE OF REVIEW Medical thoracoscopy provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it achieves therapeutic goals of fluid drainage, guided chest tube placement, and pleurodesis. RECENT FINDINGS Comparable diagnostic yield is achieved with the flexi-rigid pleuroscope even though pleural biopsies are smaller using the flexible forceps as compared to rigid thoracoscopy. Flexi-rigid pleuroscopy is extremely well tolerated and can be performed safely as an outpatient procedure. Biopsy quality can be further enhanced with accessories that are compatible with the flex-rigid pleuroscope such as the insulated tip knife and cryoprobe. SUMMARY With more sensitive tools to image the pleura such as contrast-enhanced computed tomography, MRI, ultrasonography, PET, increased yield with image-guided biopsy as well as advances in cytopathology, what lies in the future for medical thoracoscopy remains to be seen. However, it is the authors' opinion that medical thoracoscopy will evolve with time, complement novel techniques, and continue to play a pivotal role in the evaluation of pleuropulmonary diseases.
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Meghji J, Simpson H, Squire SB, Mortimer K. A Systematic Review of the Prevalence and Pattern of Imaging Defined Post-TB Lung Disease. PLoS One 2016; 11:e0161176. [PMID: 27518438 PMCID: PMC4982669 DOI: 10.1371/journal.pone.0161176] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/01/2016] [Indexed: 12/31/2022] Open
Abstract
Background Tuberculosis is an important risk factor for chronic respiratory disease in resource poor settings. The persistence of abnormal spirometry and symptoms after treatment are well described, but the structural abnormalities underlying these changes remain poorly defined, limiting our ability to phenotype post-TB lung disease in to meaningful categories for clinical management, prognostication, and ongoing research. The relationship between post-TB lung damage and patient-centred outcomes including functional impairment, respiratory symptoms, and health related quality of life also remains unclear. Methods We performed a systematic literature review to determine the prevalence and pattern of imaging-defined lung pathology in adults after medical treatment for pleural, miliary, or pulmonary TB disease. Data were collected on study characteristics, and the modality, timing, and findings of thoracic imaging. The proportion of studies relating imaging findings to spirometry results and patient morbidity was recorded. Study quality was assessed using a modified Newcastle-Ottowa score. (Prospero Registration number CRD42015027958) Results We identified 37 eligible studies. The principle features seen on CXR were cavitation (8.3–83.7%), bronchiectasis (4.3–11.2%), and fibrosis (25.0–70.4%), but prevalence was highly variable. CT imaging identified a wider range of residual abnormalities than CXR, including nodules (25.0–55.8%), consolidation (3.7–19.2%), and emphysema (15.0–45.0%). The prevalence of cavitation was generally lower (7.4–34.6%) and bronchiectasis higher (35.0–86.0%) on CT vs. CXR imaging. A paucity of prospective data, and data from HIV-infected adults and sub-Saharan Africa (sSA) was noted. Few studies related structural damage to physiological impairment, respiratory symptoms, or patient morbidity. Conclusions Post-TB structural lung pathology is common. Prospective data are required to determine the evolution of this lung damage and its associated morbidity over time. Further data are required from HIV-infected groups and those living in sSA.
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Affiliation(s)
- Jamilah Meghji
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Hope Simpson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - S. Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Kevin Mortimer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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18
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Abstract
Although it is curable, tuberculosis remains one of the most frequent causes of pleural effusions on a global scale, especially in developing countries. Tuberculous pleural effusion (TPE) is one of the most common forms of extrapulmonary tuberculosis. TPE usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. The gold standard for the diagnosis of TPE remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli, Although adenosine deaminase and interferon-γ in pleural fluid have been documented to be useful tests for the diagnosis of TPE. It can be accepted that in areas with high tuberculosis prevalence, the easiest way to establish the diagnosis of TPE in a patient with a lymphocytic pleural effusion is to generally demonstrate a adenosine deaminase level above 40 U/L. The recommended treatment for TPE is a regimen with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin.
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Affiliation(s)
- Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yong Lu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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Sharan LA, Price TP, Hehn B, Manoff D, Cowan SW. A 22-year-old man with pleural tuberculosis associated hydropneumothorax: Case report and literature review. Respir Med Case Rep 2016; 18:27-30. [PMID: 27144114 PMCID: PMC4840424 DOI: 10.1016/j.rmcr.2016.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/25/2022] Open
Abstract
A 22-year-old Asian male presented with fever, non-productive cough, right-sided pleuritic chest pain and was found to have a large right hydropneumothorax. A chest tube was placed. Pleural fluid analysis revealed a lymphocytic predominant exudate and he was subsequently started on four-drug daily anti-tuberculosis therapy (isoniazid, ethambutol, rifampin, pyrazinamide). Pleural biopsy revealed acid-fast bacilli. Given his persistent pleural effusion, he was given four doses of intrapleural tissue plasminogen activator (tPA) and dornase alpha (DNase) via his chest tube over a period of 6 days resulting in clinical and radiologic improvement. Pleural biopsy and pleural fluid culture specimens later revealed Mycobacterium tuberculosis. Intrapleural tPA-DNase therapy has demonstrated improved resolution of infections and shortened hospitalizations for parapneumonic infectious effusions. However, there is little literature on the use of intrapleural fibrinolytics specifically for pleural tuberculosis associated effusions. Furthermore, the American Thoracic Society does not comment on therapeutic thoracentesis or intrapleural fibrinolytic therapy in their recommendations for treatment of pleural tuberculosis. In our case of pleural TB-associated hydropneumothorax, the use of intrapleural tPA-DNase therapy facilitated pleural fluid drainage and resulted in near-complete resolution of the effusion.
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Key Words
- ADA, adenosine deaminase
- AFB, acid fast bacilli
- CT, chest tube
- CXR, chest radiograph
- EMB, ethambutol
- Fibrinolytic therapy
- HD, hospital day
- INH, isoniazid
- PZA, pyrazinamide
- Pleural effusion
- Pleural tuberculosis
- RIF, rifampin
- TB, tuberculosis
- Tuberculosis
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Affiliation(s)
- Lauren A. Sharan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thea P. Price
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Boyd Hehn
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - David Manoff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott W. Cowan
- Department of Surgery, Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
- Corresponding author. Thoracic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 607, Philadelphia, PA 19107, USA.Thoracic SurgeryThomas Jefferson University Hospital1025 Walnut StreetSuite 607PhiladelphiaPA19107USA
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Xiong Y, Gao X, Zhu H, Ding C, Wang J. Role of medical thoracoscopy in the treatment of tuberculous pleural effusion. J Thorac Dis 2016; 8:52-60. [PMID: 26904212 DOI: 10.3978/j.issn.2072-1439.2016.01.34] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Fibrous tuberculous pleural effusion (TPE) represents common disease in tuberculous clinic. Medical thoracoscopy has been used to treat pleural empyema and shown promising outcomes, but data of its use in multiloculated and organized TPE remains limited to know. METHODS The study was performed on 430 cases with TPE. The cases were divided into free-flowing, multiloculated effusion and organized effusion group. Each group was subdivided into two or three types of therapeutic approaches: ultrasound guided pigtail catheter, large-bore tube chest drainage and medical thoracoscopy. Patients with multiloculated or organized effusions received streptokinase, introduced into the pleural cavity via chest tubes. The successful effectiveness of the study was defined as duration of chest drainage, time from treatment to discharge days and no further managements. RESULTS Patients with organized effusion were older than those with free-flowing effusion and incidence of organized effusion combined with pulmonary tuberculosis (PTB) was higher than those of multiloculated effusion and free-flowing effusion respectively. Positive tuberculosis of pleural fluid culture was higher in organized effusion than that in free-flowing effusion. Sputum positive for acid-fast bacillus (AFB) in organized effusion was higher than that in multiloculated effusion and free-flowing effusion. Medical thoracoscopy showed significant efficacy in the group of multiloculated effusion and organized effusion but free-flowing effusion. No chronic morbidity and mortality related to complications was observed. CONCLUSIONS Medical thoracoscopy was a safe and successful method in treating multiloculated and organized TPE.
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Affiliation(s)
- Yu Xiong
- 1 Department of TB clinic, 2 Centre of Thoracoscopic Surgery, Shandong Chest Hospital, Shandong Tuberculosis Control Center, Jinan 250013, China ; 3 Department of Biomedicine, University of Bergen, Bergen, Norway ; 4 ChiNor Research Network, Neurosurgical Department of Qilu Hospital, Brain Science Research Institute, Shandong University, Jinan 250012, China
| | - Xusheng Gao
- 1 Department of TB clinic, 2 Centre of Thoracoscopic Surgery, Shandong Chest Hospital, Shandong Tuberculosis Control Center, Jinan 250013, China ; 3 Department of Biomedicine, University of Bergen, Bergen, Norway ; 4 ChiNor Research Network, Neurosurgical Department of Qilu Hospital, Brain Science Research Institute, Shandong University, Jinan 250012, China
| | - Huaiyang Zhu
- 1 Department of TB clinic, 2 Centre of Thoracoscopic Surgery, Shandong Chest Hospital, Shandong Tuberculosis Control Center, Jinan 250013, China ; 3 Department of Biomedicine, University of Bergen, Bergen, Norway ; 4 ChiNor Research Network, Neurosurgical Department of Qilu Hospital, Brain Science Research Institute, Shandong University, Jinan 250012, China
| | - Caihong Ding
- 1 Department of TB clinic, 2 Centre of Thoracoscopic Surgery, Shandong Chest Hospital, Shandong Tuberculosis Control Center, Jinan 250013, China ; 3 Department of Biomedicine, University of Bergen, Bergen, Norway ; 4 ChiNor Research Network, Neurosurgical Department of Qilu Hospital, Brain Science Research Institute, Shandong University, Jinan 250012, China
| | - Jian Wang
- 1 Department of TB clinic, 2 Centre of Thoracoscopic Surgery, Shandong Chest Hospital, Shandong Tuberculosis Control Center, Jinan 250013, China ; 3 Department of Biomedicine, University of Bergen, Bergen, Norway ; 4 ChiNor Research Network, Neurosurgical Department of Qilu Hospital, Brain Science Research Institute, Shandong University, Jinan 250012, China
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Cohen LA, Light RW. Tuberculous Pleural Effusion. Turk Thorac J 2015; 16:1-9. [PMID: 29404070 DOI: 10.5152/ttd.2014.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 12/11/2014] [Indexed: 12/12/2022]
Abstract
When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult.
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Affiliation(s)
- Leah A Cohen
- Internal Medicine Resident, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University Medical Center, Nashville, TN, USA
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Agha MA, El-Habashy MM, Helwa MA, Habib RM. Role of thoracentesis in the management of tuberculous pleural effusion. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Critchley JA, Orton LC, Pearson F. Adjunctive steroid therapy for managing pulmonary tuberculosis. Cochrane Database Syst Rev 2014; 2014:CD011370. [PMID: 25387839 PMCID: PMC6532561 DOI: 10.1002/14651858.cd011370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tuberculosis causes approximately 8.6 million disease episodes and 1.3 million deaths worldwide per year. Although curable with standardized treatment, outcomes for some forms of tuberculosis are improved with adjunctive corticosteroid therapy. Whether corticosteroid therapy would be beneficial in treating people with pulmonary tuberculosis is unclear. OBJECTIVES To evaluate whether adjunctive corticosteroid therapy reduces mortality, accelerates clinical recovery or accelerates microbiological recovery in people with pulmonary tuberculosis. SEARCH METHODS We identified studies indexed from 1966 up to May 2014 by searching: Cochrane Infectious Diseases Group's trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and LILACS using comparative search terms. We handsearched reference lists of all identified studies and previous reviews and contacted relevant researchers, organizations and companies to identify grey literature. SELECTION CRITERIA Randomized controlled trials and quasi-randomized control trials of recognized antimicrobial combination regimens and corticosteroid therapy of any dose or duration compared with either no corticosteroid therapy or placebo in people with pulmonary tuberculosis were included. DATA COLLECTION AND ANALYSIS At least two investigators independently assessed trial quality and collected data using pre-specified data extraction forms. Findings were reported as narrative or within tables. If appropriate, Mantel-Haenszel meta-analyses models were used to calculate risk ratios. MAIN RESULTS We identified 18 trials, including 3816 participants, that met inclusion criteria. When compared to taking placebo or no steroid, corticosteroid use was not shown to to reduce all-cause mortality, or result in higher sputum conversion at 2 months or at 6 months (mortality: RR 0.77, 95%CI 0.51 to 1.15, 3815 participants, 18 studies, low quality evidence; sputum conversion at 2 months RR 1.03, 95%CI 0.97 to 1.09, 2750 participants, 12 studies; at 6 months; RR1.01, 95%CI 1.01, 95%CI 0.98 to 1.04, 2150 participants, 9 studies, both low quality evidence). However, corticosteroid use was found to increase weight gain (data not pooled, eight trials, 1203 participants, low quality evidence), decrease length of hospital stay (data not pooled, three trials, participants 379, very low quality of evidence) and increase clinical improvement within one month (RR 1.16, 95% CI 1.09 to 1.24; five trials, 497 participants, low quality evidence). AUTHORS' CONCLUSIONS It is unlikely that adjunctive corticosteroid treatment provides major benefits for people with pulmonary tuberculosis. Short term clinical benefits found did not appear to be maintained in the long term. However, evidence available to date is of low quality. In order to evaluate whether adjunctive corticosteroids reduce mortality, or accelerate clinical or microbiological recovery in people with pulmonary tuberculosis further large randomized control trials sufficiently powered to detect changes in such outcomes are needed.
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Affiliation(s)
- Julia A Critchley
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
| | - Lois C Orton
- University of LiverpoolSchool of Population, Community and Behavioural SciencesDivision of Public HealthWhelan Building, Brownlow HillLiverpoolUKL69 3GB
| | - Fiona Pearson
- St George's, University of LondonPopulation Health Sciences InstituteCranmer TerraceLondonUKSW17 0RE
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Jeon D. Tuberculous pleurisy: an update. Tuberc Respir Dis (Seoul) 2014; 76:153-9. [PMID: 24851127 PMCID: PMC4021261 DOI: 10.4046/trd.2014.76.4.153] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 02/07/2014] [Accepted: 02/14/2014] [Indexed: 11/29/2022] Open
Abstract
Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis in Korea. Tuberculous pleurisy presents a diagnostic and therapeutic problem due to the limitations of traditional diagnostic tools. There have been many clinical research works during the past decade. Recent studies have provided new insight into the tuberculous pleurisy, which have a large impact on clinical practice. This review is a general overview of tuberculous pleurisy with a focus on recent findings on the diagnosis and management.
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Affiliation(s)
- Doosoo Jeon
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
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26
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Ferreiro L, San José E, Valdés L. Tuberculous pleural effusion. Arch Bronconeumol 2014; 50:435-43. [PMID: 24721286 DOI: 10.1016/j.arbres.2013.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/28/2022]
Abstract
Tuberculous pleural effusion (TBPE) is the most common form of extrapulmonary tuberculosis (TB) in Spain, and is one of the most frequent causes of pleural effusion. Although the incidence has steadily declined (4.8 cases/100,000population in 2009), the percentage of TBPE remains steady with respect to the total number of TB cases (14.3%-19.3%). Almost two thirds are men, more than 60% are aged between 15-44years, and it is more common in patients with human immunodeficiency virus. The pathogenesis is usually a delayed hypersensitivity reaction. Symptoms vary depending on the population (more acute in young people and more prolonged in the elderly). The effusion is almost invariably a unilateral exudate (according to Light's criteria), more often on the right side, and the tuberculin test is negative in one third of cases. There are limitations in making a definitive diagnosis, so various pleural fluid biomarkers have been used for this. The combination of adenosine deaminase and lymphocyte percentage may be useful in this respect. Treatment is the same as for any TB. The addition of corticosteroids is not advisable, and chest drainage could help to improve symptoms more rapidly in large effusions.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - Esther San José
- Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
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Diagnostic utility of sonar guided biopsy in tuberculous effusion. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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28
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Critchley JA, Young F, Orton L, Garner P. Corticosteroids for prevention of mortality in people with tuberculosis: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:223-37. [PMID: 23369413 DOI: 10.1016/s1473-3099(12)70321-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effects of corticosteroids are systemic, but their benefits in tuberculosis are thought to be organ specific, with clinicians using them routinely to treat some forms of tuberculosis (such as meningitis), but not others. We aimed to assess the effects of steroids on mortality attributable to all forms of tuberculosis across organ systems. METHODS We did a systematic review and meta-analysis to estimate the efficacy of steroids for the prevention of mortality in all forms of tuberculosis, and to quantify heterogeneity in this outcome between affected organ systems. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Central Register of Controlled Trials, Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) for studies published up to Sept 6, 2012, and checked reference lists of included studies and relevant reviews. We included all trials in people with tuberculosis in any organ system, with tuberculosis defined clinically or microbiologically. There were no restrictions by age, comorbidity, publication language, or type, dose, or duration of steroid treatment. We used the Mantel-Haenszel method to summarise mortality across trials. FINDINGS We identified 41 eligible trials, 18 of which assessed pulmonary tuberculosis. 20 of the 41 trials (including 13 of those for pulmonary tuberculosis) were done before the introduction of modern rifampicin-containing antituberculosis chemotherapy. Meta-analysis stratified by affected organ systems identified no heterogeneity; steroids reduced mortality by 17% (risk ratio [RR] 0·83, 95% CI 0·74-0·92; I(2) 0%), consistent across all organ groups. In a sensitivity analysis that only included trials that used rifampicin-containing regimens, the results were similar (RR 0·85, 95% CI 0·74-0·98; I(2) 21%). A sensitivity analysis in pulmonary tuberculosis that excluded trials with high potential risks of bias suggested a slight benefit, but the point estimate was closer to no effect and the difference was not significant (RR 0·93, 95% CI 0·60-1·44). INTERPRETATION Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis. FUNDING UK Department for International Development.
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Affiliation(s)
- Julia A Critchley
- Division of Population Health Sciences and Education, St George's, University of London, London, UK.
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Abstract
For centuries the treatment of TB has presented an enormous challenge to global health. In the 20th century, the treatment of TB patients with long-term multidrug therapy gave hope that TB could be controlled and cured; however, contrary to these expectations and coinciding with the emergence of AIDS, the world has witnessed a rampant increase in hard-to-treat cases of TB, along with the emergence of highly virulent and multidrug-resistant Mycobacterium tuberculosis strains. Unfortunately, these bacteria are now circulating around the world, and there are few effective drugs to treat them. As a result, the prospects for improved treatment and control of TB in the 21st century have worsened and we urgently need to identify new therapies that deal with this problem. The potential use of immunotherapy for TB is now of greater consideration than ever before, as immunotherapy could potentially overcome the problem of drug resistance. TB immunotherapy targets the already existing host anti-TB immune response and aims to enhance killing of the bacilli. For this purpose, several approaches have been used: the use of anti-Mycobacteria antibodies; enhancing the Th1 protective responses by using mycobacterial antigens or increasing Th1 cytokines; interfering with the inflammatory process and targeting of immunosuppressive pathways and targeting the cell activation/proliferation pathways. This article reviews our current understanding of TB immunity and targets for immunotherapy that could be used in combination with current TB chemotherapy.
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Affiliation(s)
- Mercedes Gonzalez-Juarrero
- Department of Microbiology, Immunology & Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, CO 80523, USA.
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Aslangul E, Le Jeunne C. Place des corticoïdes dans le traitement des infections. Presse Med 2012; 41:400-5. [DOI: 10.1016/j.lpm.2012.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 12/19/2011] [Accepted: 01/04/2012] [Indexed: 10/14/2022] Open
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Abstract
The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of gamma-interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.
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Affiliation(s)
- Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee 37232-2650, USA.
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Shu CC, Wu HD, Yu MC, Wang JT, Lee CH, Wang HC, Wang JY, Lee LN, Yu CJ, Yang PC. Use of high-dose inhaled corticosteroids is associated with pulmonary tuberculosis in patients with chronic obstructive pulmonary disease. Medicine (Baltimore) 2010; 89:53-61. [PMID: 20075705 DOI: 10.1097/md.0b013e3181cafcd3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of high-dose inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) has recently been shown to increase the incidence of pneumonia. However, to our knowledge, the impact of high-dose ICS on pulmonary tuberculosis (TB) has never been investigated. To study that impact, we conducted a retrospective study including patients aged more than 40 years old with irreversible airflow limitation between August 2000 and July 2008 in a medical center in Taiwan. Of the 36,684 patients who underwent pulmonary function testing, we included 554 patients. Among them, patients using high-dose ICS (equivalent to >500 microg/d of fluticasone) were more likely to have more severe COPD and receive oral corticosteroids than those using medium-dose, low-dose, or no ICS. Sixteen (3%) patients developed active pulmonary TB within a follow-up of 25,544 person-months. Multivariate Cox regression analysis revealed that the use of high-dose ICS, the use of 10 mg or more of prednisolone per day, and prior pulmonary TB were independent risk factors for the development of active pulmonary TB. Chest radiography and sputum smear/culture for Mycobacterium tuberculosis should be performed before initiating high-dose ICS and regularly thereafter.
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Affiliation(s)
- Chin-Chung Shu
- From Department of Traumatology (CCS), Department of Internal Medicine (HDW, JTW, HCW, JYW, CJY, PCY), and Department of Laboratory Medicine (LNL), National Taiwan University Hospital, Taipei; Department of Internal Medicine (MCY), Taipei Medical University-Wan Fang Hospital, Taipei; Department of Internal Medicine (CHL), Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei; and the TAMI group, Taiwan
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Semi-rigid thoracoscopy for undiagnosed exudative pleural effusions: a comparative study. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200808010-00010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kwon JS, Cha SI, Jeon KN, Kim YJ, Kim EJ, Kim CH, Park JY, Jung TH. Factors influencing residual pleural opacity in tuberculous pleural effusion. J Korean Med Sci 2008; 23:616-20. [PMID: 18756047 PMCID: PMC2526418 DOI: 10.3346/jkms.2008.23.4.616] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Tuberculous pleural effusion (TPE) leads to residual pleural opacity (RPO) in a significant proportion of cases. The aim of this study was to investigate which TPE patients would have RPO following the treatment. This study was performed prospectively for a total of 60 TPE patients, who underwent pleural fluid analysis on the initial visit and chest radiographs and computed tomography (CT) scans before and after the administration of antituberculous medication. At the end of antituberculous medication, the incidence of RPO was 68.3% (41/60) on CT with a range of 2-50 mm. Compared with the non-RPO group, the RPO group had a longer symptom duration and lower pleural fluid glucose level. On initial CT, loculation, extrapleural fat proliferation, increased attenuation of extrapleural fat, and pleura-adjacent atelectasis were more frequent, and parietal pleura was thicker in the RPO group compared with the non-RPO group. By multivariate analysis, extrapleural fat proliferation, loculated effusion, and symptom duration were found to be predictors of RPO in TPE. In conclusion, RPO in TPE may be predicted by the clinico-radiologic parameters related to the chronicity of the effusion, such as symptom duration and extrapleural fat proliferation and loculated effusion on CT.
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Affiliation(s)
- Jee-Sook Kwon
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung-Ick Cha
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung-Nyeo Jeon
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Joo Kim
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eun-Jin Kim
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chang-Ho Kim
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae-Yong Park
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Hoon Jung
- Department of Internal Medicine and Respiratory Center, Kyungpook National University School of Medicine, Daegu, Korea
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The use of adjunctive corticosteroids in the treatment of pericardial, pleural and meningeal tuberculosis: do they improve outcome? Respir Med 2008; 102:793-800. [PMID: 18407484 DOI: 10.1016/j.rmed.2008.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 01/24/2008] [Indexed: 02/08/2023]
Abstract
Tuberculosis remains a major cause of mortality and morbidity on a global scale. Effective anti-tuberculous chemotherapy has improved outcomes for individuals suffering from tuberculosis, although the disease often results in significant and permanent damage to organs. The use of adjunctive corticosteroid treatment has been studied with a view to demonstrating a reduction in inflammatory events that may improve outcomes for both mortality and morbidity. Cochrane reviews have summarized the evidence for adjunctive corticosteroids in the treatment of tuberculous pericarditis, meningitis and pleural effusion. These reviews have shown improved mortality for pericarditis and meningitis, but inconclusive effects for pericardial constriction and ongoing neurological disability. Rapid improvements in clinical parameters for pleural effusion were not supported by any lasting improved outcomes for these patients.
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Abstract
BACKGROUND Corticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent, raising doubt as to whether such treatment is worthwhile. Concern also exists regarding the potential adverse effects of corticosteroids, especially in HIV-positive people. OBJECTIVES To evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion. SEARCH STRATEGY In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, Current Controlled Trials, and reference lists of articles. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing any corticosteroid with no treatment, placebo, or other active treatment (both groups should receive the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI). The fixed-effect model was applied in the absence of statistically significant heterogeneity. MAIN RESULTS Six trials with 633 participants met the inclusion criteria; one trial included only HIV-positive people. Compared to control, corticosteroid use was associated with less residual pleural fluid at four weeks (RR 0.76, 95% CI 0.62 to 0.94; 394 participants, 3 trials) and reduced pleural thickening (RR 0.69, 95% CI 0.51 to 0.94; 309 participants, 4 trials). We found no evidence of an effect of corticosteroids on death from any cause (194 participants, 1 trial), respiratory function (191 participants, 2 trials), residual pleural fluid at eight weeks (399 participants, 4 trials), or pleural adhesions (123 participants, 2 trials). Although discontinuation of treatment due to adverse events was more frequent in participants receiving corticosteroids than placebo (RR 2.80, 95% CI 1.12 to 6.98; 586 participants, 6 trials), the effects were generally mild. The risk of Kaposi sarcoma may be increased in HIV-positive people receiving corticosteroids (RR 13.00, 95% CI 0.74 to 227.63; 194 participants, 1 trial). AUTHORS' CONCLUSIONS There are insufficient data to support evidence-based recommendations regarding the use of adjunctive corticosteroids in people with tuberculous pleurisy. Randomized controlled trials that are sufficiently powered to evaluate the effects of corticosteroids on both morbidity and mortality are needed. The effects of corticosteroids on HIV-related complications, such as Kaposi sarcoma, should be assessed in people co-infected with HIV.
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Affiliation(s)
- M E Engel
- Faculty of Health Sciences, University of Cape Town, Department of Medicine, J47 Old Main Building, Groote Schuur Hospital, Observatory, South Africa, 7925.
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Domínguez-Castellano A, Del Arco A, Canueto-Quintero J, Rivero-Román A, Kindelán JM, Creagh R, Díez-García F. Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis. Enferm Infecc Microbiol Clin 2007; 25:519-34. [PMID: 17915111 DOI: 10.1157/13109989] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(+) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(+) patients (< or = 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy.
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Abstract
BACKGROUND The aim of this study was to describe the clinical characteristics and potentially diagnostic specimens of pediatric patients with tuberculous pleural effusion (TPE) to make a prompt diagnosis. METHODS Children who had TPE from September 1997 to December 2003 were retrospectively reviewed at a tertiary pediatric facility in northern Taiwan. RESULTS There were seven boys and six girls and their ages ranged from 10 to 17 years (average, 14.6 years). Tuberculosis contact history was identified in only six patients (46%). Fever (12/92%), cough (9/69%) and malaise (6/46%) were the most common symptoms. Normal leukocyte count was found in 12 patients (92%). Chest radiograph review showed unilateral pleural effusion in 12 patients (92%) but parenchymal involvement was found in nine patients (69%). Most of the pleural fluid analysis showed a lymphocytic exudative effusion (5/6). The acid-fast bacilli (AFB) stain of sputum, gastric washing, and pleural aspirate was positive in six of 11 (55%), two of seven (29%), and one of five (20%) patients, respectively. Culture of sputum, gastric washing, and pleural aspirate yielded Mycobacterium tuberculosis in four of 11 (36%), two of seven (29%), and two of five (40%) patients, respectively. A total of 6 to 9 months of multiple-drug therapy for tuberculosis was successful without sequale. CONCLUSIONS Tuberculous pleural effusion usually presents as an acute illness and should always be considered in the differential diagnosis for older children and adolescents with pneumonia. A normal leukocyte count with a lymphocytic exudative effusion may provide a clue to the correct diagnosis of TPE. Diagnostic specimen of sputum seems more effective and sensitive in childhood TPE, especially those having pulmonary involvement.
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Affiliation(s)
- Chih-Yung Chiu
- Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Children's Hospital, Taoyuan, Taiwan
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Gopi A, Madhavan SM, Sharma SK, Sahn SA. Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest 2007; 131:880-889. [PMID: 17356108 DOI: 10.1378/chest.06-2063] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Tuberculous (TB) pleural effusion occurs in approximately 5% of patients with Mycobacterium tuberculosis infection. The HIV pandemic has been associated with a doubling of the incidence of extrapulmonary TB, which has resulted in increased recognition of TB pleural effusions even in developed nations. Recent studies have provided insights into the immunopathogenesis of pleural TB, including memory T-cell homing and chemokine activation. The definitive diagnosis of TB pleural effusions depends on the demonstration of acid-fast bacilli in the sputum, pleural fluid, or pleural biopsy specimens. The diagnosis can be established in a majority of patients from the clinical features, pleural fluid examination, including cytology, biochemistry, and bacteriology, and pleural biopsy. Measurement of adenosine deaminase and interferon-gamma in the pleural fluid and polymerase chain reaction for M tuberculosis has gained wide acceptance in the diagnosis of TB pleural effusions. Although promising, these tests require further evaluation before their routine use can be recommended. The treatment of TB pleural effusions in patients with HIV/AIDS is essentially similar to that in HIV-negative patients. At present, evidence regarding the use of corticosteroids in the treatment of TB pleural effusion is not clear-cut.
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Affiliation(s)
- Arun Gopi
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sethu M Madhavan
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Surendra K Sharma
- The Division of Pulmonary and Critical Care Medicine, Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Steven A Sahn
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
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Cases Viedma E, Lorenzo Dus MJ, González-Molina A, Sanchis Aldás JL. A study of loculated tuberculous pleural effusions treated with intrapleural urokinase. Respir Med 2006; 100:2037-42. [PMID: 16580190 DOI: 10.1016/j.rmed.2006.02.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 01/26/2006] [Accepted: 02/10/2006] [Indexed: 11/25/2022]
Abstract
AIM To assess the effect of intrapleural urokinase, vis-à-vis simple pleural drainage, on residual pleural thickening in a series of patients suffering from loculated tuberculous pleural effusion. PATIENTS AND METHOD Twenty-nine patients (21 males and 8 females) with loculated pleural effusion were studied. These patients were randomly allocated to one of two groups: one group received intrapleural urokinase (n=12) and the other was treated by simple drainage with suction (n=17). The urokinase (125,000 UI) was administered into the pleural cavity via an intrathoracic tube. This procedure was repeated every 12h until the quantity of pleural fluid obtained was less than 50 cm3, at which point the intrathoracic tube was removed. RESULTS In both groups, the biochemical analysis of the pleural fluid was an exudate and the fluid had a serous appearance. Pleural thickening when the drainage tube was removed was 8.09+/-3.36 mm for the group treated with urokinase, and 14.78+/-17.20mm (P>0.05) for the control group. Residual pleural thickening measured upon completion of medical treatment at 6 months was 1.45+/-0.89 mm for the group treated with urokinase and 7.47+/-10.95 mm for the control group (P<0.05). In the control group, only two patients presented over 10mm of residual pleural thickening. The mean quantity of fluid drained in the two groups was 1.487+/-711 ml for the patients with urokinase, and 795+/-519 ml for the control group (P<0.01). CONCLUSION Our study shows that patients with loculated tuberculous pleural effusion treated with urokinase suffered less from residual pleural thickening, as measured after six months, than those treated by simple drainage. It is therefore suggested that the administration of intrapleural urokinase is a safe and effective treatment for those patients who drain a larger quantity of pleural fluid.
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Affiliation(s)
- Enrique Cases Viedma
- Neumology Department, La Fe University Hospital, Avenida Campanar, 21, 46009 Valencia, Spain.
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Abstract
Pleural fibrosis can result from a variety of inflammatory processes. The response of the pleural mesothelial cell to injury and the ability to maintain its integrity are crucial in determining whether normal healing or pleural fibrosis occurs. The pleural mesothelial cell, various cytokines, and disordered fibrin turnover are involved in the pathogenesis of pleural fibrosis. The roles of these mediators in producing pleural fibrosis are examined. This article reviews the most common clinical conditions associated with the development of pleural fibrosis. Fibrothorax and trapped lung are two unique and uncommon consequences of pleural fibrosis. The management of pleural fibrosis, including fibrothorax and trapped lung, is discussed.
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Affiliation(s)
- Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, 1600 SW Archer Road, Room M352, PO Box 100225, Gainesville, FL 32610-0225, USA.
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Abstract
Tuberculosis (TB) can spread to any tissue or organ of the body by way of hematogenous or lymphatic dissemination or contiguity. However, pulmonary TB is the most common presentation and the only form of the disease of epidemiologic importance. Consequently, the literature on the various forms of extrapulmonary TB (EPTB) is scant, and most of the published authors are specialists in specific extrapulmonary forms. As a result, in most of the major areas of study of EPTB, recommendations similar to those for pulmonary TB or others based on little or no evidence have been accepted. This lack of evidence is of particular concern in the case of treatment guidelines. The present article reviews important work that has given rise to current treatment guidelines. While most of these guidelines reveal the lack of evidence available on this subject, it can, nevertheless, be concluded that a 6-month treatment regimen similar to that used in patients with pulmonary TB may be sufficient to treat all forms of EPTB, including meningeal disease. The role of steroids and surgery in the treatment of TB affecting different sites is also discussed. Other topics dealt with are the considerations that should be taken into account and the treatment modifications necessary in patients infected with the human immunodeficiency virus.
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Affiliation(s)
- Z M Fuentes
- Servicio de Neumología, Hospital General Dr. José Ignacio Baldó, El Algodonal, Caracas, Venezuela
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Fuentes Z, Caminero J. Controversias en el tratamiento de la tuberculosis extrapulmonar. Arch Bronconeumol 2006. [DOI: 10.1157/13086625] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Wong CF, Leung SKF, Yew WW. Percentage reduction of pleural effusion as a simple predictor of pleural scarring in tuberculous pleuritis. Respirology 2006; 10:515-9. [PMID: 16135177 DOI: 10.1111/j.1440-1843.2005.00743.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the utility of serum and pleural fluid biomarkers for predicting residual pleural scarring (RPS) in tuberculous pleuritis. METHODOLOGY A retrospective study of patients with pleural tuberculosis was performed. Demographic data, clinical parameters, haematological indices, serum and pleural fluid biochemistry and pleural effusion area were assessed for correlation with the extent of RPS. RESULTS RPS was found in 41.4% of the 70 cases evaluated, with significant pleural scarring being present in 7.1%. It was more common in males (odds ratio 5.55). Among the variables studied, only the percentage reduction of the effusion after 2 weeks of treatment was found to independently predict the extent of RPS (r=-0.502, P<0.001). CONCLUSION RPS was more common in males and the percentage reduction in pleural effusion on CXR after 2 weeks of treatment was found to be a useful predictor of RPS.
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Affiliation(s)
- Chi-Fong Wong
- Tuberculosis and Chest Unit, Grantham Hospital, Hong Kong, China.
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Choi GH, Choi GM, Kim HS, Cho SJ, Ryu SM, Ahn HC, Seo JY. Results of Application of Video-Assisted Thoracoscopic Surgery for the Treatment of Empyema Thoracis. Tuberc Respir Dis (Seoul) 2006. [DOI: 10.4046/trd.2006.61.5.463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Gi Hoon Choi
- Department of Emergency Medicine, College of Medicine, Hallym University, Korea
| | - Goang Min Choi
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Korea
| | - Seong Joon Cho
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Kangwon National University, Korea
| | - Se Min Ryu
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Kangwon National University, Korea
| | - Hee Cheol Ahn
- Department of Emergency Medicine, College of Medicine, Hallym University, Korea
| | - Jeong Yeol Seo
- Department of Emergency Medicine, College of Medicine, Hallym University, Korea
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Han DH, Song JW, Chung HS, Lee JH. Resolution of Residual Pleural Disease According to Time Course in Tuberculous Pleurisy During and After the Termination of Antituberculosis Medication. Chest 2005; 128:3240-5. [PMID: 16304268 DOI: 10.1378/chest.128.5.3240] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To assess the resolution of pleural disease in patients with tuberculous pleurisy (TP) during and after antituberculosis medication. DESIGN An observational, prospective, longitudinal study. SETTING University-affiliated general hospital in Seoul, Korea. PATIENTS AND METHODS Chest radiographs of 85 adult TP patients were followed up prospectively from diagnosis to 24 months after the start of medication. The extent of pleural disease, synonymous with the radiographic term, pleural opacity (PO), was evaluated at regular intervals according to a size scale. Additionally, following completion of 6 months of therapy, residual PO (RPO) was determined by either measurement of the widest width of the opacity, if loculated, or at the superior level of the hemidiaphragm. RESULTS Seventy-seven patients had a PO graded > or = 2 at the initial presentation. At 6, 9, and 24 months, the number of patients with these grades declined. At these time periods, there were 14, 8, and 7 patients, respectively, remaining with this classification. RPO > 10 mm at 24 months was considered indicative of significant residual pleural disease. During the period after 6 months of antituberculosis medication, the number of patients with RPO > or = 10 mm declined from 43 patients at 6 months to 21 patients at 24 months. The presence of loculation on an initial chest decubitus view was associated with significant RPO at 24 months (p = 0.009). CONCLUSION In TP patients, improvement of RPO often occurred even after completion of 6 months of antituberculosis medication up to 24 months. A loculated PO at initial presentation, but not initial PO size, was a predictor of significant RPO at 24 months.
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Affiliation(s)
- Dae-Hee Han
- Departments of Radiology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Korea
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48
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Abstract
Management of patients with tuberculous pleuritis can be improved by establishing early diagnosis accurately, administering effective chemotherapy, and close monitoring of progress for early detection and prompt management of severe pleural inflammation in the hope of preventing or reducing subsequent residual pleural fibrosis. In addition to the conventional diagnostic tools, chemical markers, especially pleural fluid adenosine deaminase and interferon-gamma levels and new microbiological tests such as polymerase chain reaction and BACTEC culture of pleural biopsy specimens for Mycobacterium tuberculosis, can increase the diagnostic yield for tuberculous pleuritis. Indicators of the severity of pleural inflammation, including high pleural fluid tumour necrosis factor-alpha and lysozyme levels, and low pleural fluid glucose and pH, can help to predict residual pleural fibrosis. It is likely that patients will require surgery: (i) complete drainage of pleural fluid for prevention; and (ii) pleurectomy for the treatment of residual pleural fibrosis.
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Affiliation(s)
- Poon-Chuen Wong
- Tuberculosis & Chest Unit, Grantham Hospital, Aberdeen, Hong Kong, China.
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Chang B, Wu AW, Hansel NN, Diette GB. Quality of life in tuberculosis: a review of the English language literature. Qual Life Res 2005; 13:1633-42. [PMID: 15651535 DOI: 10.1007/s11136-004-0374-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Tuberculosis (TB) studies have concentrated on clinical outcomes; few studies have examined the impact of TB on patients' quality of life (QOL). METHODS A systematic review of published medical literature using specific MESH terms: [Tuberculosis] and 1-[Outcome], 2-[Outcome Assessment], 3-[Quality of Life], 4-[Mood Disorder], 5-[Cost and Cost Analysis], 6-[Religion], 7-[Perception], 8-[Social Support], 9-[Optimism], 10-[Stress], 11-[Signs and Symptoms], and 12-[Cost of Illness]. This yielded 1972 articles; 60 articles met inclusion criteria and were reviewed. RESULTS TB somatic symptoms have been well studied, but there were no studies of effects on physical functioning or general health perceptions. Patients tend to be worried, frustrated, or disappointed by their diagnosis, but it is unknown how emotional health changes with treatment. Diagnosed patients are less likely to find work, and less able to work and care for their families. TB creates the greatest financial burden on the poor. In developing, countries, patients and their families are ostracized by society, and families sometimes ostracize patients; the extent of TB's social stigma in the developed countries is unknown. CONCLUSION There has been relatively little research on TB QOL and even less in developed countries. A better understanding may help improve treatment regimens, adherence to treatment, and functioning and well-being of people with TB.
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Affiliation(s)
- Betty Chang
- Johns Hopkins University, Baltimore, MD, USA.
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50
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Abstract
Pleural infection is responsible for significant morbidity and mortality worldwide, and its clinical management is challenging. The diagnosis of empyema and tuberculous pleurisy may be difficult, and these conditions may be confused with other causes of exudative pleural effusions. Complicated parapneumonic effusion or empyema may present with 'atypical' clinical features; delays in diagnosis are common and may contribute to the high mortality of these infections. Pleural aspiration is the key diagnostic step; pleural fluid that is purulent or that has a pH < 7.2, or organisms on Gram stain or culture, is an indication for formal intercostal drainage. In order to achieve a definitive diagnosis of tuberculous pleurisy, Mycobacterium tuberculosis must be isolated in the culture of pleural fluid, pleural tissue or sputum; demonstration of granulomas in pleural tissue is also suggestive of tuberculosis. The use of pleural fluid biochemical markers, such as adenosine deaminase, in the diagnosis of tuberculous pleurisy varies among clinicians; the diagnostic value of such markers is affected by the background prevalence of tuberculosis and the likelihood of an alternative diagnosis. Uncertainties also remain regarding the treatment of pleural infection. Treatment of complicated parapneumonic effusion and empyema involves prolonged courses of antibiotics and attention to the patient's nutritional state. The role of intrapleural fibrinolytics and the optimal timing of surgical intervention are unknown. The lack of clear predictors of clinical outcome in empyema contributes to the difficulty in treating this condition. The pharmacological treatment of tuberculous pleurisy is the same as for pulmonary tuberculosis; the precise role of steroids in the treatment of tuberculous pleurisy remains uncertain.
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Affiliation(s)
- Stephen J Chapman
- Wellcome Trust Centre for Human Genetics, Oxford University, Oxford, UK.
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