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TB pleural effusion
林倬睿醫師
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Outlines • Introduction• Etiology & pathogenesis• Symptoms, laboratory & radiologic
findings • Diagnosis• Treatment & management• Complications
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Introduction
• 是由結核菌感染肋膜所引起• 通常為 exudate, 可以同時合併肺部病灶• 為最常見的肺外結核表現• HIV患者若 CD4數目較高 , 則 TB pleural
effusion發生率較高 ,可見 TB pleural effusion的形成不只是感染 ,更是一種免疫反應 (immunological response)
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Etiology & pathogenesis• Mycobacterial protein access pleural
cavity through a rupture of a subpleural focus
• TB protein mesothelial/endothelial cells cytokines neutrophils, lymphocytes, monocytes, etc
• Pleural fluid: neutrophil in the early phase, highly suggestive of TB if lymphocyte > 85%
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Mycobacteria liposaccharides
Mesothelial / endothelial cells
IL-1, IL-6, TNF- α chemokines-α chemokines-
IL-8, NAP2 MIP-1, MCP-1, TNF- α
Neutrophil, lymphocyte
Activated lymphocyte
Th1
IL-12, IFN-ɤ
IL-1, TNF- α
Mesothelial cell
Monocyte- macrophage Mycobacteria
ADA1
ADA2-ADA1
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• HIV pt 因免疫反應差 , 在 effusion中較常發現 TB 菌 ,biopsy中則較少見granuloma
• Effusion的形成雖與免疫反應有關 ,但得到 TB pleurisy不表示就因此產生抵抗力 ,若未治療 ,即使自然痊癒 ,將來仍有超過65%會發生 active pulmonary TB
• TB可以躲在macrophage中
Etiology & pathogenesis
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Symptoms • Male : female = 3 : 1• Mostly < 35y/o or > 70y/o• Acute or subacute onset• S/S to diagnosis: < 1month• Cough, fever, chest pain, dyspnea• HIV pt: hepatosplenomegaly, LAP, less
PPD (+)
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Laboratory findings
• Non-specific (ESR , normal WBC)
• Pleural effusion:– color : serofibrinous, serosanguinous– exudate– lymphocyte predominant– exclude TB, if : eosinophil > 10%
mesothelial cell > 5%
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Radiological findings
• Usually unilateral, small to moderate in size
• 30% 的病人在同側肺實質有radiological disease
• HIV pt 的 effusion量較多 ,雙側有水的機會也比一般人高
• Primary: lower lobe involvement & LAP
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Diagnosis
• Presumption: prevalence, HIV co-infection, pleural effusion, clinical symptoms
• Definite diagnosis: – M. TB in sputum or effusion– caseous granulomas in the pleura
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(A) P.E. with atelectasis
(B) anechoic (C) complex nonseptated
(D) complex septated
(E) homogenously echogenic
(F) parapneumonic effusion
(G) malignant effusion
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Granuloma of Tuberculosis
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• Positive sputum culture rate:– 30–50% in pleural + lung involvement– only 4% in pleural involvement alone
• Diagnostic methods:– pleural effusion culture: 23-86%– biopsy culture: 39-71%– presence of necrotizing caseous granuloma
in biopsy: most efficient, 51-87%– all combined: 82-98%
Diagnosis
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Diagnosis
• Among HIV pt:
– more positive sputum culture
– more AFB (+) in pleural effusion
– more positive biopsy culture
– less granuloma formation
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Diagnosis • Conventional method: pleural biopsy• New methods:
– finding TB: radiometric culture system,
PCR– measure parameters caused by
immunological-metabolic mechanism:
adenosine deaminase (ADA), IFN-ɤ, etc
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Diagnosis
• Radiometric culture system:– accelerate diagnosis by 2-3 weeks
• PCR– rapid– identify the type of mycobacteria– determine susceptibility to drugs– not that reliable, requires QC procedure
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• ADA (adenosine deaminase)– Pleural TB infection increased metabolic
activity of the monocytes & macrophages increased production of ADA
– High levels of ADA: TB pleurisy, empyema, malignant lymphoma, collagen-vascular disease
– Sensitivity: 77-100%, specificity: 81-97%
Diagnosis
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• ADA (adenosine deaminase)– Association with L/N ratio > 0.75 or <
35y/o greatly improves the specificity– No differences with regard to HIV status– May be a better negative predictive
parameter– ADA1: ubiquitous– ADA2: only in monocytes, macrophages
Diagnosis
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• IFN-ɤ– relative good sensitivity & specificity– False positive: parapneumonic effusion,
lymphoma, malignancy– Disadvantage: expensive, slow
• Others – Lysozyme, tuberculostearic acid,
monoclonal antibody, cytokines
Diagnosis
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Treatment
• Spontaneous resolution in 2-4 months in healthy individuals
• 65% will develop pulmonary tuberculosis in 5 years
• So, it is important to treat pleural tuberculosis
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• Should be monitored by official public health center– Ensure correct treatment– Prevent the emergence of resistant strain– Evaluation of contacts– Monitor the pattern of resistances – Provide education to the patients– Identify possible outbreaks
Treatment
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• As pulmonary TB, combination therapy is preferred– Reducing the population of mycobacteria– Without creating resistance– Sterilizing the lesions during prolonged
treatment phase
Treatment
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• Duration: 6 month is recommended• Number of drugs: HRZ for 2 months,
then HR for 4 months. • Add EMB if
– Local resistance to INAH > 4%– High levels of resistance are reported– Received anti-TB drug previously– Exposed to MDR-TB patients
Treatment
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• Some may show an increase of pleural effusion during the initial phase
• Standard treatment is recommended for HIV patients.
• If the clinical or bacteriological response is slow or less than optimal prolong treatment
Treatment
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• Use of steroid
– Insufficient evidence to prove that steroid
can reduce inflammation and subsequent
residual pachypleuritis–不如在診斷性抽水時把水抽乾一點
Treatment
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Complications
• Residual pleural thickening
– Most frequent
– Incidence varies according to the time of
evaluation and the degree of thickness
– No variable idetified
– Minimal impact on lung functions
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• Tuberculous empyema– Unusual, normally related to BP fistula– Response to medical treatment is limited– Frequently requires thoracotomy and/or
decortication– May consider repeated thoracentesis with
prolonged medical treatment
• Thoracic wall infection– Rare, 1/106
Complications
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Thanks for your attention!