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Jung MK, Lee SY, Min EJ, Ko JM. CT Scan Differences of Pulmonary TB According to Presence of Pleural Effusion. Chest 2023; 164:1387-1395. [PMID: 37423294 DOI: 10.1016/j.chest.2023.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Subpleural micronodules and interlobular septal thickening are common CT scan findings in TB pleural effusion. These CT scan features could help us differentiate between TB pleural effusion and nonTB empyema. RESEARCH QUESTION Does the frequency of subpleural micronodules and interlobular septal thickening correlate with the presence of pleural effusion in patients with pulmonary TB? STUDY DESIGN AND METHODS CT scan findings of pulmonary TB, micronodules and their distribution (peribronchovascular, septal, subpleural, centrilobular, and random), large opacity (consolidation/macronodule), cavitation, tree-in-buds, bronchovascular bundle thickening, interlobular septal thickening, lymphadenopathy, and pleural effusion were retrospectively analyzed. Patients were divided into two groups according to the presence of pleural effusion. Clinicoradiologic findings of the two groups were then analyzed. We presented Benjamini-Hochberg critical value for multiple testing correction of CT scan findings, with a false discovery rate of 0.05. RESULTS Of a total of 338 consecutive patients diagnosed with pulmonary TB who underwent CT scans, 60 were excluded because of coexisting pulmonary diseases. The frequency of subpleural nodules (47/68, 69% in pulmonary TB with pleural effusion vs 30/210, 14% in pulmonary TB without effusion, P < .001, Benjamini-Hochberg [B-H] critical value = 0.0036) and interlobular septal thickening (55/68, 81% vs 134/210, 64%, P = .009, B-H critical value = 0.0107) was significantly higher in the group of patients with pulmonary TB with pleural effusion than in the group without pleural effusion. In contrast, tree-in-buds (20/68, 29% vs 101/210, 48%, P = .007, B-H critical value = 0.0071) were less frequently seen in patients with pulmonary TB with pleural effusion. INTERPRETATION Subpleural nodules and septal thickening were more common in pulmonary TB patients with pleural effusion than in those without pleural effusion. TB involvement of the lymphatics in the peripheral interstitium could be associated with the development of pleural effusion.
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Affiliation(s)
- Min Kyung Jung
- Department of Radiology St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Young Lee
- Department of Radiology St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jeong Min
- Department of Medical Life Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Min Ko
- Department of Radiology St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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McNally E, Ross C, Gleeson LE. The tuberculous pleural effusion. Breathe (Sheff) 2023; 19:230143. [PMID: 38125799 PMCID: PMC10729824 DOI: 10.1183/20734735.0143-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease. Educational aims To demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.
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Affiliation(s)
- Emma McNally
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
| | - Clare Ross
- Department of Respiratory Medicine, Imperial NHS Healthcare Trust, London, UK
| | - Laura E. Gleeson
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
- Department of Clinical Medicine, Trinity College Dublin School of Medicine, St James's Hospital, Dublin, Ireland
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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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Diagnosis of tuberculous pleural effusions: A review. Respir Med 2021; 188:106607. [PMID: 34536698 DOI: 10.1016/j.rmed.2021.106607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023]
Abstract
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
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Thori R, Desai GS, Pande P, Narkhede R, Vardhan A, Mehta H. “Video Assisted Thoracoscopic Surgery (VATS) for all Stages of Empyema Thoracis: a Single Centre Experience”. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02042-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Marušić A, Kuhtić I, Mažuranić I, Janković M, Glodić G, Sabol I, Stanić L. Nodular distribution pattern on chest computed tomography (CT) in patients diagnosed with nontuberculous mycobacteria (NTM) infections. Wien Klin Wochenschr 2020; 133:470-477. [PMID: 32617707 DOI: 10.1007/s00508-020-01701-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 06/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study evaluated the prevalence of spreading pathways in nontuberculous mycobacteria (NTM) pulmonary infections according to nodular distribution patterns seen on chest computed tomography (CT). METHODS This study included 63 patients diagnosed with NTM lung infections who underwent CT at our institution. A retrospective analysis of CT images focused on the presence and distribution of nodules, presence of intrathoracic lymphadenopathy and the predominant side of infection in the lungs. The findings were classified into five groups; centrilobular (bronchogenic spread), perilymphatic (lymphangitic spread), random (hematogenous spread), combined pattern and no nodules present. The groups were then compared according to other CT findings. RESULTS Among 51 (81%) patients identified with a nodular pattern on chest CT, 25 (39.8%) presented with centrilobular, 7 (11.1%) with perilymphatic, 6 (9.5%) with random and 13 (20.6%) with combined nodular patterns but located in different areas of the lungs. The right side of the lungs was predominant in 38 cases (60.3%). Intrathoracic lymphadenopathy was evident in 20 patients (31.7%). Significant differences in distributions of nodular patterns were seen in patients infected with Mycoplasma avium complex (MAC) associated with centrilobular pattern (p = 0.0019) and M. fortuitum associated with random pattern (p = 0.0004). Some of the findings were related to perilymphatic nodules between other isolated species of NTM (p = 0.0379). CONCLUSION The results of this study showed a high proportion of perilymphatic nodules and right-sided predominance in the upper lobe, which, combined with intrathoracic lymphadenopathy is highly suggestive of the lymphangitic spread of lung NTM infections.
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Affiliation(s)
- Ante Marušić
- Department of Radiology, Thoracic radiology, University Hospital Center, University of Zagreb Medical School, Kišpatićeva 12, 10 000, Zagreb, Croatia.
| | - Ivana Kuhtić
- Department of Radiology, Thoracic radiology, University Hospital Center, University of Zagreb Medical School, Kišpatićeva 12, 10 000, Zagreb, Croatia
| | - Ivica Mažuranić
- Department of Radiology, Thoracic radiology, University Hospital Center, University of Zagreb Medical School, Kišpatićeva 12, 10 000, Zagreb, Croatia
| | - Mateja Janković
- Department for Respiratory Diseases, University Hospital Center, University of Zagreb Medical School, Kišpatićeva, Zagreb, Croatia
| | - Goran Glodić
- Department for Respiratory Diseases, University Hospital Center, University of Zagreb Medical School, Kišpatićeva, Zagreb, Croatia
| | - Ivan Sabol
- Division of Molecular medicine, Laboratory of Molecular Virology and Bacteriology, Ruder Boskovic Institute, Bijenička cesta, Zagreb, Croatia
| | - Lucija Stanić
- Emergency Department of Zagreb County, Matice Hrvatske, Zagreb, Croatia
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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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Denning DW, Page ID, Chakaya J, Jabeen K, Jude CM, Cornet M, Alastruey-Izquierdo A, Bongomin F, Bowyer P, Chakrabarti A, Gago S, Guto J, Hochhegger B, Hoenigl M, Irfan M, Irurhe N, Izumikawa K, Kirenga B, Manduku V, Moazam S, Oladele RO, Richardson MD, Tudela JLR, Rozaliyani A, Salzer HJF, Sawyer R, Simukulwa NF, Skrahina A, Sriruttan C, Setianingrum F, Wilopo BAP, Cole DC, Getahun H. Case Definition of Chronic Pulmonary Aspergillosis in Resource-Constrained Settings. Emerg Infect Dis 2019; 24. [PMID: 30016256 PMCID: PMC6056117 DOI: 10.3201/eid2408.171312] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a recognized complication of pulmonary tuberculosis (TB). In 2015, the World Health Organization reported 2.2 million new cases of nonbacteriologically confirmed pulmonary TB; some of these patients probably had undiagnosed CPA. In October 2016, the Global Action Fund for Fungal Infections convened an international expert panel to develop a case definition of CPA for resource-constrained settings. This panel defined CPA as illness for >3 months and all of the following: 1) weight loss, persistent cough, and/or hemoptysis; 2) chest images showing progressive cavitary infiltrates and/or a fungal ball and/or pericavitary fibrosis or infiltrates or pleural thickening; and 3) a positive Aspergillus IgG assay result or other evidence of Aspergillus infection. The proposed definition will facilitate advancements in research, practice, and policy in lower- and middle-income countries as well as in resource-constrained settings.
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Sodhi KS, Bhalla AS, Mahomed N, Laya BF. Imaging of thoracic tuberculosis in children: current and future directions. Pediatr Radiol 2017; 47:1260-1268. [PMID: 29052772 DOI: 10.1007/s00247-017-3866-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/11/2017] [Accepted: 04/09/2017] [Indexed: 12/18/2022]
Abstract
Tuberculosis continues to be an important cause of morbidity and mortality worldwide. It is the leading cause of infection-related deaths worldwide. Children are amongst the high-risk groups for developing tuberculosis and often pose a challenge to the clinicians in making a definitive diagnosis. The newly released global tuberculosis report from World Health Organization reveals a 50% increase in fatality from tuberculosis in children. Significantly, diagnostic and treatment algorithms of tuberculosis for children differ from those of adults. Bacteriologic confirmation of the disease is often difficult in children; hence radiologists have an important role to play in early diagnosis of this disease. Despite advancing technology, the key diagnostic imaging modalities for primary care and emergency services, especially in rural and low-resource areas, are chest radiography and ultrasonography. In this article, we discuss various diagnostic imaging modalities used in diagnosis and treatment of tuberculosis and their indications. We highlight the use of US as point-of-care service along with mediastinal US and rapid MRI protocols, especially in mediastinal lymphadenopathy and thoracic complications. MRI is the ideal modality in high-resource areas when adequate infrastructure is available. Because the prevalence of tuberculosis is highest in lower-resource countries, we also discuss global initiatives in low-resource settings.
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Affiliation(s)
- Kushaljit Singh Sodhi
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education & Research (PGIMER), Sector-12, Chandigarh, 160012, India.
| | - Ashu S Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nasreen Mahomed
- Department of Radiology, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Bernard F Laya
- Institute of Radiology, St. Luke's Medical Center-Global City, Taguig City, Philippines
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Porcel JM, Pardina M, Alemán C, Pallisa E, Light RW, Bielsa S. Computed tomography scoring system for discriminating between parapneumonic effusions eventually drained and those cured only with antibiotics. Respirology 2017; 22:1199-1204. [PMID: 28370693 DOI: 10.1111/resp.13040] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/04/2017] [Accepted: 02/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Due to limited data, we aimed to develop and validate a computed tomography (CT)-based scoring system for identifying those parapneumonic effusions (PPEs) requiring drainage. METHODS A retrospective review of all patients with PPE who underwent thoracentesis and a chest CT scan before any attempt to place a tube thoracostomy, if applicable, over an 8-year period was conducted. Eleven chest CT characteristics were compared between 90 patients with complicated PPEs (CPPEs), defined as those which eventually required chest drainage, and 60 with non-complicated effusions (derivation sample). A scoring system was devised with those CT findings identified as independent predictors of CPPE in a logistic regression analysis, and further validated in an independent population of 59 PPE patients. RESULTS CT scores predicting CPPE were pleural contrast enhancement (3 points), pleural microbubbles, increased extrapleural fat attenuation and fluid volume ≥400 mL (1 point each). A sum score of ≥4 yielded 84% sensitivity (95% CI: 62-85%), 75% specificity (95% CI: 62-85%), 81% diagnostic accuracy (95% CI: 73-86%), likelihood ratio (LR) positive of 3.4 (95% CI: 2.1-5.4), LR negative of 0.22 (95% CI: 0.13-0.36) and area under the receiver operating characteristic curve (AUC) of 0.829 (95% CI: 0.754-0.904) for labelling CPPE in the derivation set. These results were reproduced in the validation sample. The CT grading scale also exhibited a fair ability to identify patients who needed surgery or would die from the pleural infection (AUC: 0.76, 95% CI: 0.61-0.9). CONCLUSION A novel CT scoring system for adults with PPE may allow clinicians to predict the need for chest tube drainage with good accuracy.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Lleida, Spain.,Institute for Biomedical Research in Lleida Dr Pifarré Foundation, IRBLLEIDA, Lleida, Spain
| | - Marina Pardina
- Institute for Biomedical Research in Lleida Dr Pifarré Foundation, IRBLLEIDA, Lleida, Spain.,Department of Radiology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Carmen Alemán
- Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Esther Pallisa
- Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Richard W Light
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silvia Bielsa
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Lleida, Spain.,Institute for Biomedical Research in Lleida Dr Pifarré Foundation, IRBLLEIDA, Lleida, Spain
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