Pleural TB

What is Pleural Tuberculosis?

Pleural TB is the only exception of all extra-pulmonary TB which affects the lungs

But, first, what is pleurisy? It is an inflammation of the double layered membrane (called pleura) around the lung which lubricates and protects the lungs

What are the causes of Pleurisy?

Commonest – Viral infections

Lung infections as tuberculosis and pneumonia

Other diseases as systemic lupus erythematous (lupus)

Rheumatoid arthritis

Pulmonary embolism

Chest injuries

Drug reactions

How serious is Pleurisy?

Only as serious as the causing disease!

Medical attention required if you are having pleurisy but not getting it treated

Symptoms of Pleurisy?

Pleuritic chest pain is sharp and gets worse on coughing and breathing

The pain may remain in one specific area, or spread to back or shoulder

Relief from this Pleuritic pain often comes by lying on the affected side

Patient of Pleurisy with pneumonia may get high fever

shortness of breath

Cough

Sputum is thick, dark & yellow

the patient has shortness of breath

low-grade fever

and a blood cough that brings up blood

The patient shows unexplained weight loss along-with cough when due to lung cancer

Those with rheumatic fever may have pain and swelling in several joints

Pleurisy due to Tuberculosis :

The route of the tubercular organisms is via the lymphatics going counter current to the pleura
- From the Hilar lymphadenopathy
- Bacteria via ulcerated lesions
- TB bacteria going directly into the pleural cavity
- Sub-acute or acute haematogenous tuberculosis also causes pleurisy
- The process of pleural effusion causes extensive pleural thickening and nodule formation.
- The route is by pleural congestion, followed by leukocyte infiltration, forming serous exudate.

How to confirm diagnosis?

Physical examination by medical practitioner, with special attention to your lungs

The doctor checks for signs of pleural effusion by gentle tapping of chest wall

On examination by stethoscope one can hear the pleural friction rub, the scratchy, rough, sound of the inflamed pleura which slides past each other during breathing

Mycobacterial stain and culture
- Usually overlooked. Underutilized.
- To work-up the patients with an undiagnosed pleural effusion is to examine the sputum for mycobacteria. Presence in almost 50% cases.
- Look for mycobacterium in the pleural fluid. Present in upto 45% cases.

Chest X-ray —
- Will show areas of pulmonary embolism, pneumonia, pulmonary tuberculosis, pleural effusion or cancerous nodule.
- When quantity of pleural effusion is less than 300ml, the PA view of the chest may not show positive findings except blunting of the costophrenic angle.
- When fluid volume goes upto 500ml, there is fluid accumulation in lower chest / then costophrenic becomes sharp angle, shows increase in lateral lung density.
- Moderate pleural effusion gives higher density of lower shadow, covering diaphragm, liquid makes a low medial arc shadow.
- When large pleural effusion is large, lung field remains uniform, dense shadows covering the diaphragm with a shift in the mediastinal line.

Blood tests —
- Adenosine deaminase Test, ADA is the enzyme which catalyzes the conversion of adenosine to inosine and deoxyadenosine to deoxyinosine. The increase in ADA activity is due to monocyte/macrophages produced in tuberculous pleurisy.
- There are two main problems about interpretating of ADA level, and that is , it can show false-negative or false-positive results. In early phase of tuberculous pleurisy, level can be low, but subsequent ADA levels are high in almost all patients at repeat testing.
- If ADA is more than 70 U/L, the diagnosis of tuberculous pleurisy is almost confirmed and antituberculous treatment can be started.
- If ADA is between 40 and 70 U/L, a presumptive diagnosis for TB can be made.
- If ADA level is below 40 U/L, then diagnosis of tuberculosis is less likely.
- If patient has An almost typical clinical picture of tuberculous pleurisy, then it can be further evaluated by needle biopsy or by thoracoscopy.

Ultrasound or CT scan is to be got done in suspect cases of pleural effusion, which usually confirms an abnormal fluid pocket in the lungs

Pleural biopsy is done (thoracentesis) in which chest fluid is taken and sent to laboratory for testing. The tuberculous pleural fluid is generally clear and straw colored, but may be turbid .The effusion is usually an exudate, with lymphocytic predominance in about 90% of cases. Neutrophils may predominate in first 2 weeks after onset of symptoms, but lymphocytic predominance increases afterwards

Differential Diagnosis of Pleural TB

Bacterial pneumonia
- With symptoms of fever, chest pain, shortness of breath, coughing, blood leucocytosis along with findings in chest X-ray showing high-density uniform shadow, can be often misdiagnosed as pneumonia.
- But in pneumonia the cough and phlegm is more, which is often of rusty type and doing sputum smear or culture will show pathogens.
- In tuberculous pleurisy there is dry cough, signs of effusion in chest are seen and very often the PPD test becomes positive.

Class pneumonia, pleural effusion
- This takes place in presence of lung abscess and bronchiectasis associated with pleural effusion.
- In many patients with a background history of pulmonary disease, the pleural fluid shows white blood cells and culture shows growth of many pathogenic bacteria

Malignant pleural effusion
- Cancers of the Lung, breast, lymphoma, or pleural metastasis causes pleural effusion.
- Most common is lung cancer.
- Systemic lupus erythematous
- Rheumatoid pleurisy with pleural effusion is possible, but these diseases have their clinical features, but still identification is difficult.

Complications

Leaves get formed

Mediastinal pleurisy

Formation of encapsulated fluid

Lung bottom effusions

Treatment of Pleural TB

General treatment
- When body temperature is above 38, the patient is to stay in bed .
- The total time for rest can be for 2-3 months when pleural fluid has disappeared completely.

Pleural puncture fluid
- To drain the high tuberculous pleural fluid for 2-3 times a week so that pleural adhesions do not get formed.
- First pumping of fluid not to more than 700ml, subsequent draining of upto 1000ml, but not more than 1500ml.
- If there is dizziness, weak pulse, sweating, pale cold extremities, low blood pressure and other reactions, then to immediately stop the pumping.
- To make the above symptoms disappear, a subcutaneous injection of 0.5% epinephrine of 0.5ml, with intravenous injection of dexamethasone 5 -10mg To be done.
- The drainage reduces symptoms, accelerates cooling, and relieves pressure on the lungs and heart blood vessels.
- Early aspiration reduces chances of pleural thickening.

Use of anti-TB drugs
- General use of streptomycin, isoniazid and rifampicin.
- OR combination of streptomycin ,isoniazid and ethambutol.
- Streptomycin injection dose to be 0.75 -1.0g / d, intramuscular injection, for 2 – 3 months treatment.
- TB drugs to be taken during the treatment of side effects, when changes in hearing, vision or liver function, happens, then to be stopped or reduced.

Routine use of corticosteroids not advised due to a lot of side effects. But when pleural effusion is large, then a dosage of 40 mg/d to be used in reducing dosage every week by 10 mg. Dosages to be adjusted to avoid rebound fluid or toxic symptoms

The prognosis of pleural TB-

When treatment is timely and correct, the prognosis is good

To avoid pleural adhesions, parcels

Some malnutrition possible due to prolonged use, this can affect prognosis

Pleural TB

Pleural TB

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