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Hiding in plain sight: Diagnosing pleural tuberculosis using lung ultrasound

Ahmed WAW, Rahim MJC, Mohammad N, Fauzi MH, Wahab SFA

Ultrasound, 2021 May;29(2):123-127.
PMID: 33995559 DOI: 10.1177/1742271X20959761

Introduction: Diagnosing pleural tuberculosis can be difficult in patients with ambiguous presentation, especially in resource-limited health centres. Thus, lung ultrasound had been studied as a novel method in helping clinicians to diagnose this condition.
Case presentation: A 48-year-old woman presented with worsening dyspnoea and orthopnoea for one week. She had also experienced weight loss, minimal dry cough and right-sided pleuritic chest pain for several weeks. A chest radiograph showed a right lower zone pleural effusion with no apparent lung consolidation. Lung ultrasound showed a right apical consolidation and right lower zone septated pleural effusion. Pleural fluid investigations showed exudative features of mixed lymphocytic, mesothelial and neutrophilic cellular components. Tuberculin skin test was strongly positive. She was subsequently treated for pleural tuberculosis. One month after treatment, her symptoms had improved considerably.
Discussion: Lung ultrasound has been found to be more effective than chest radiograph in detecting consolidation and diagnosing pneumonia. The portability and efficacy of today's ultrasound machines, including the handheld types, show that lung ultrasound is a practical, reliable and valuable diagnostic tool in managing pulmonary conditions including tuberculosis, provided that the operators are adequately trained.
Conclusion: Lung ultrasound in tuberculosis is the next frontier for clinicians and researchers.

Matched MeSH terms: Pleural Effusion
Fulltext Cystic teratoma mimicking recurrent pleural effusion, complicated by Mycobacterium abscessus infection

Mohd Esa NY, Mohd Radzi AA, Bakar NS, Mohd Khalid MS, Ismail AI, Abdul Rani MF

Respirol Case Rep, 2016 May;4(3):e00155.
PMID: 27516884 DOI: 10.1002/rcr2.155

Teratomas of anterior mediastinum are rare. They are often slow growing, asymptomatic, and detected incidentally on chest imaging. Mycobacterium abscessus (M. abscessus) is an acid-fast bacillus that is classified as a pathogenic "rapid growing" non-tuberculous mycobacteria. It is an uncommon cause of human pathology, which may cause skin and soft tissue infection after skin injury following inoculation, minor trauma, and surgery. Here, we present an unusual case of benign cystic teratoma mimicking recurrent pleural effusion, which was subsequently complicated by M. abscessus infection following thoracotomy. Cystic teratoma is rare, but it needs to be considered whenever clinical and investigative work-up fails to provide a convincing diagnosis. A combined clinical, radiological, surgical, and histopathological assessment is important to arrive at the correct diagnosis. Rapidly growing mycobacteria needs to be included in the differential diagnosis of patients with non-resolving infected post-thoracotomy wound and who do not respond to broad-spectrum antibiotics.

Matched MeSH terms: Pleural Effusion
Chest wall stretching exercise as an adjunct modality in post operative pulmonary management

Vikram, M., Joseph, Leonard H., Kamaria, K.

Journal of Surgical Academia, 2012;2(1):39-41.
MyJurnal

Emphysematous pyelonephritis is a form of infection of the kidney. Chest physiotherapy was executed on a 15-year-old girl who had complications such as secretion retention and pleural effusion following percutaneous pigtail nephrostomy in addition to oxygen therapy and medical management to promote respiratory functions. The processes to increase chest wall mobility includes particular passive stretching and mobilization. Chest mobility exercises composed of an intercostal stretch on a determined intercostal space using index fingers, thoracic rotation and anterior compression with stretching in sitting position to improve respiratory functions. These exercises were suggested to the patient as a regular daily treatment along with low-level incentive spirometry breathing exercises. Following 9th sessions of treatment patient demonstrated satisfactory improvement by means of increasing in chest expansion and reduction in dyspnea level without using supplemental oxygen. The results expressed a substantial clinical improvement in reduction of dyspnea level and improvement in chest expansion

Matched MeSH terms: Pleural Effusion
Fulltext Disseminated AIDS-related Kaposi's sarcoma

Tang ASO, Teh YC, Chea CY, Yeo ST, Chua HH

Oxf Med Case Reports, 2018 Dec;2018(12):omy107.
PMID: 30487992 DOI: 10.1093/omcr/omy107

We present a case of disseminated Kaposi's sarcoma with both cutaneous and extracutaneous involvement in an HIV-infected patient with a relatively high CD4 count of 369 cell/mm3. He developed chronic diarrhea, constitutional symptoms, worsening bilateral pleural effusion with respiratory distress, and progression of skin lesions distributed over his chest and extremities. The temporal relationship between rapid clinical progression and initiation of HAART suggested the possibility of Kaposi's sarcoma-associated immune reconstitution inflammatory syndrome, which eventually resulted in the death of this patient.

Matched MeSH terms: Pleural Effusion
Fulltext Resolution of pleura-peritoneal fistula via transient daytime ambulatory peritoneal dialysis regime (DAPD) - 8 years follow up

Lim TS, Thong KM

Pak J Med Sci, 2016 11 25;32(5):1302-1304.
PMID: 27882041 DOI: 10.12669%2Fpjms.325.11096

Pleural effusion or hydrothorax is a relatively rare but well-recognized complication associated with peritoneal dialysis (PD). We describe the successful long term resolution of a patient who developed pleural effusions after starting continuous ambulatory peritoneal dialysis (CAPD), by altering the PD prescription to normal volume daytime ambulatory peritoneal dialysis (DAPD) transiently before resuming the usual CAPD exchanges four months later. After 8 years of follow up, there is no sign of recurrence of the effusion. Normal volume DAPD present as an attractive alternative and cheap method for resolution of pleura-peritoneal fistula.

Matched MeSH terms: Pleural Effusion
Survival study and prognostic factors of ovarian cancer registered in a teaching hospital in Malaysia

Najihah Lokman, Siti Azrin Ab. Hamid, Norsa’adah Bachok

Sains Malaysiana, 2017;46:559-565.

Ovarian cancer is one of the highest causes of death among female population in Malaysia. A retrospective cohort study among 127 ovarian cancer patients registered in one of the teaching hospital in Malaysia was conducted from 1st January 2002 until 31st December 2011. The objective of this study was to determine the median survival time, five year survival probability and prognostic factors of ovarian cancer patients. Only ovarian cancer patients were selected with strict inclusion and exclusion criteria. Data was analyzed using Kaplan-Meier Survival analysis and Cox proportional hazard regression analysis. The results showed that the overall five-year survival probability of ovarian cancer was 35.2% (95%CI: 26.3, 44.3) with 38 month (95%CI: 25.7, 50.1) median survival time. After adjustment for potential cofounder, significant prognostic factors of ovarian cancer were observed in FIGO stage (HR: 2.53; 1.44, 4.45), loss of appetite (HR: 1.95; 1.23, 3.11) and presence of pleural effusion (HR: 1.98; 1.19, 3.30). Overall, the survival probabilities of ovarian cancer were low and further actions must be taken to improve the survival among advanced cancer patients

Matched MeSH terms: Pleural Effusion
Fulltext Pulmonary Tuberculosis in HIV Infection : The Relationship of the Radiographic Appearance to CD4 T-Lymphocytes Count

San KE, Muhamad M

Malays J Med Sci, 2001 Jan;8(1):34-40.
PMID: 22973154

Pulmonary tuberculosis (TB) in the AIDS population has a variable chest radiographic presentation. The association between the chest radiographic presentation of pulmonary TB and CD4 T-lymphocyte count in the HIV-infected patient was investigated in order to provide an empirical approach for early diagnosis, treatment, and isolation of these patients. A retrospective analysis of chest radiographs, CD4 T-lymphocyte counts, and clinical history of 80 patients from Hospital Kota Bharu, was performed. All patients were HIV-seropositive and had culture and /or cytology-proven pulmonary tuberculosis. Radiographs were evaluated for the presence of atypical or typical patterns of pulmonary TB. Thirteen (16.2%) patients had typical postprimary pattern, where opacities were distributed at the upper zones, with or without cavitation. Sixty-seven (83.8%) patients had atypical patterns, consisting of normal chest radiograph, middle and/or lower zones parenchymal opacities, mediastinal lymphadenopathy, pleural effusion and miliary TB. Of these, 18 (22.5%) patients demonstrated normal chest radiographs, 36 (45%) patients showed parenchymal opacities at the middle and/or lower zones of the lungs, 30 (37.5%) had mediastinal lymphadenopathy, 18 (22.5%) revealed pleural effusion and 6 (7.5%) presented with miliary TB. Sixty-two (77.5%) patients had CD4 T-lymphocytes count less than 200 cells/ul. Of these patients, only 1 (1.6%) had typical pattern. Eighteen (22.5%) patients had CD4 T-lymphocyte count more than 200 cells/ul, where 12 (66.7%) of them showed typical pattern. Patients with CD4 T-lymphocytes count of less than 200 cells/ul, were more likely to produce normal chest radiographs, middle and /or lower zones parenchymal opacities and mediastinal lymphadenopathy. The mean CD4 T-lymphocytes count were also found significantly lower. AIDS patients with pulmonary TB can present with both typical and atypical chest radiograph patterns. An AIDS patient who had CD4 T-lymphocytes count less than 200 cells/ul were more likely to present with atypical radiographic appearance of pulmonary TB. They required appropriate treatment and isolation until the diagnosis of pulmonary TB was confirmed.

Matched MeSH terms: Pleural Effusion
Rapid detection of Mycobacterium tuberculosis in clinical samples by multiplex polymerase chain reaction (mPCR)

Tang TH, Ahmed SA, Musa M, Zainuddin ZF

World J Microbiol Biotechnol, 2013 Dec;29(12):2389-95.
PMID: 23807412 DOI: 10.1007/s11274-013-1407-0

Although the multi-copy and specific element IS6110 provides a good target for the detection of Mycobacterium tuberculosis complex by PCR techniques, the emergence of IS6110-negative strains suggested that false negative may occur if IS6110 alone is used as the target for detection. In this report, a multiplex polymerase chain reaction (mPCR) system was developed using primers derived from the insertion sequence IS6110 and an IS-like elements designated as B9 (GenBank accession no. U78639.1) to overcome the problem of detecting negative or low copy IS6110 containing strains of M. tuberculosis. The mPCR was evaluated using 346 clinical samples which included 283 sputum, 19 bronchial wash, 18 pleural fluid, 9 urine, 7 CSF, 6 pus, and 4 gastric lavage samples. Our results showed that the sensitivity (93.1 %) and specificity (89.6 %) of the mPCR system exceeds that of the conventional method of microscopy and culture. The mPCR assay provides an efficient strategy to detect and identify M. tuberculosis from clinical samples and enables prompt diagnosis when rapid identification of infecting mycobacteria is necessary.

Matched MeSH terms: Pleural Effusion/microbiology
Fulltext Intrapleural streptokinase for the treatment of chylothorax

Kuan YC, How SH, Ng TH, Abdul Rani MF

Respir Care, 2011 Dec;56(12):1953-5.
PMID: 21682984 DOI: 10.4187/respcare.01207

Chylothorax is suspected when milky white turbid fluid is obtained from thoracocentesis. Conservative management usually involves intercostal tube drainage, dietary restriction, and total parenteral nutrition. Surgery is indicated when conservative management fails. We describe a young woman with idiopathic chylothorax who failed conservative therapy but refused surgery. We instilled intrapleural streptokinase, which improved her condition.

Matched MeSH terms: Pleural Effusion/metabolism
An apparently healthy young man with a peculiar-looking chest radiograph

Khajotia R, Manthari K

Can Fam Physician, 2011 Mar;57(3):311-3.
PMID: 21402968
Matched MeSH terms: Pleural Effusion/radiography*
Fulltext Diagnostic flex-rigid pleuroscopic biopsy of parietal pleura for exudative pleural effusions in suspected malignant and tuberculosis cases: a retrospective study of 219 cases

Lad L, Samsudin AT, Kannan K, Makki JS, Mohamed M

Malays J Pathol, 2015 Aug;37(2):101-7.
PMID: 26277666 MyJurnal

This study was carried out to ascertain the aetiology of exudative pleural effusions when other diagnostic investigations such as pleural fluid and sputum examination for cytology and acid fast bacilli fail to yield a definitive diagnosis and to differentiate between tuberculosis and malignancy in cases suspicious of malignancy.

Matched MeSH terms: Pleural Effusion/etiology*
Pleural fluid lactate as a point-of-care adjunct diagnostic aid to distinguish tuberculous and complicated parapneumonic pleural effusions during initial thoracentesis: Potential use in a tuberculosis endemic setting

Kho SS, Chan SK, Yong MC, Cheah HM, Lee YG, Tie ST

Respir Investig, 2020 Sep;58(5):367-375.
PMID: 32107195 DOI: 10.1016/j.resinv.2020.01.004

BACKGROUND: Tuberculous pleural effusions (TBEs) and parapneumonic pleural effusion (PPEs) have similar clinical presentations and fluid biochemistry. A pleural biopsy is usually required to diagnose TBE but complete fluid evacuation may not be necessary, contrasting with complicated PPE (CPPE). A point-of-care test that distinguishes between TBE and CPPE enables the appropriate procedures to be performed during the initial diagnostic thoracentesis. Lactate is a metabolic product measurable by a blood-gas analyzer. This study measured pleural fluid (Pf) lactate levels in TBE and compared them with those in PPE/CPPE. We hypothesized that Pf lactate would be significantly higher in PPE because of active metabolic activities than in TBE which is driven by delayed hypersensitivity.
METHODS: All patients undergoing an initial diagnostic thoracentesis over 18 months with Pf lactate measured using a calibrated point-of-care blood gas analyzer were assessed.
RESULTS: The diagnoses of the enrolled patients (n = 170) included TBE (n = 49), PPE (n = 47), malignancy (n = 63), and transudate (n = 11). Pf lactate level in TBE, median 3.70 (inter-quartile range 2.65-4.90) mmol/l, was significantly lower than in PPE and CPPE. In the subgroup of TBE and CPPE patients whose initial Pf pH and glucose could suggest either condition, Pf lactate was significantly higher in those with CPPE. Pf lactate (cutoff ≥7.25 mmol/l) had a sensitivity of 79.3%, specificity 100%, positive predictive value 100%, and negative predictive value 89.1% for discriminating CPPE from TBE (area under the curve 0.947, p

Matched MeSH terms: Pleural Effusion/diagnosis*
Diagnostic values of different cytokines in identifying tuberculous pleural effusion

Nguyen MH, Dao QM, Bui TTH, Le VHT

Trop Biomed, 2020 Jun 01;37(2):372-378.
PMID: 33612806

Interleukin (IL)-1 beta (IL-1β), IL-2, Interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α) in the pleural fluid are valuable biomarkers in early diagnosis of Tuberculous Pleural Effusion (TPE). This study aimed to analyze the diagnostic values of some cytokines (IFN-γ, TNF-α, IL-1β, and IL-2) in pleural fluid for identifying TPE in Vietnam. We performed a cross-sectional study on tuberculosis (TB) patients with pleural effusion. Pleural IFN-γ, TNF-α, IL-1β, IL-2 were measured by ELISA® Kit (Abcam, USA) on Biotek system. Receiver operating characteristic curves (ROC), an area under the curve (AUC), sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (ACC) of IFN-γ, TNF-α, IL-1β, IL-2 in identifying TBE were assessed. Among 386 patients, 234 (60,6%) had TPE, and 152 (39,4%) did not have TPE. The median of IL-2, TNF-α, and IFN-γ levels were significantly higher in TPE compared to the non-TPE group (p<0.05). AUC for IL-1β, IL-2, TNF-α, and IFN-γ were 0.54, 0.57, 0.62. 0.84 (p<0.05), respectively. The sensitivity of IL-1β, IL-2, TNF-α, and IFN-γ in the diagnosis of TPE were 82.1, 53.4, 77.8, and 80.3, while the specificity was 28,4, 69.7, 47.4, and 80.9, respectively. IFN-γ and TNF-α are potential biomarkers in diagnosing TPE.

Matched MeSH terms: Pleural Effusion/diagnosis*
Complete resolution of type B aortic intramural hematoma with medical treatment

Moorthy PS, Sakijan AS

Asian Cardiovasc Thorac Ann, 2014 Feb;22(2):231.
PMID: 24585805 DOI: 10.1177/0218492312468119
Matched MeSH terms: Pleural Effusion/etiology
Fulltext First Two Cases of Fungal Infections Associated with Multi-drug Resistant Yeast, Fereydounia khargensis

Tap RM, Ramli NY, Sabaratnam P, Hashim R, Bakri AR, Bee LB, et al.

Mycopathologia, 2016 Aug;181(7-8):531-7.
PMID: 27010640 DOI: 10.1007/s11046-016-0002-y

The number of new fungal pathogens is increasing due to growing population of immunocompromised patients and advanced identification techniques. Fereydounia khargensis is a yeast and was first described in 2014 from environmental samples. As far as we know, this is the first report of human infections associated with F. khargensis. The yeasts were isolated from blood of a HIV-positive patient and pleural fluid of chronic renal failure patient. Amplification and sequencing of the internal transcribed spacer and the large subunit regions confirmed the identity of the isolates. Both isolates showed multi-drug resistance to antifungal agents tested.

Matched MeSH terms: Pleural Effusion/microbiology
Right atrial tuberculoma: a diagnosis too late

Ngow HA, Khairina WM

Cardiol J, 2011;18(5):560-3.
PMID: 21947994

Solitary intra-cardiac cavity tuberculoma is extremely rare and often only diagnosed during a post-mortem. We report a case of right atrial tuberculoma causing right atrial outflow tract obstruction in an immune-compromised man. The diagnosis of cardiac tuberculoma was made through the detection of mycobacterium tuberculosis DNA by tuberculosis-polymerase chain reaction in the pericardial fluid. The patient succumbed five days after admission but an autopsy was refused by his family.

Matched MeSH terms: Pleural Effusion/microbiology
Fulltext Metastatic melanoma: a rare cause of central airway obstruction

Abdul Hamid MF, Ban Yu-Lin A, Hassan TM, Mohammad N

BMJ Case Rep, 2017 Nov 04;2017.
PMID: 29103009 DOI: 10.1136/bcr-2017-221545

A middle-aged woman with recurrent malignant melanoma presented initially with massive left pleural effusion. There was a complete obliteration of the left main bronchus on flexible bronchoscopy caused by a mass. Serial cryo-debulking of the tumour was done under rigid bronchoscopy; however, the outcome was not favourable due to the aggressive tumour growth. Vemurafenib was planned after thoracic radiation. She was not keen for the biologics treatment due to financial constraints. We report a case of central airway obstruction due to recurrent aggressive melanoma. More evaluations are needed on the role of interventional pulmonologist for bronchoscopic debulking of this rapidly growing tumour as well as the role of biological agents in treating such cases.

Matched MeSH terms: Pleural Effusion/etiology
Fulltext An interesting case of systemic lupus erythematosus presenting with hypercalcemia: A diagnostic dilemma

Abdul Gafor AH, Cader RA, Das S, Masir N, Wahid FA

Am J Case Rep, 2013;14:1-3.
PMID: 23569551 DOI: 10.12659/AJCR.883849

BACKGROUND: Hypercalcemia is common in primary hyperparathyroidism malignancies and even in tuberculosis. Interestingly, systemic lupus erythematosus (SLE) rarely presents with hypercalcemia.
CASE REPORT: We describe an interesting case of SLE in a patient who was otherwise thought to have either tuberculosis or a malignancy. The patient initially presented with feeling unwell, with generalized lymphadenopathy, bilateral pleural effusion, and bilateral corneal calcium deposits secondary to severe hypercalcemia. The diagnosis of SLE was made based on positivity of antinuclear antibodies (ANA) and anti-dsDNA, the presence of serositis, lymphadenopathy, autoimmune hemolytic anemia, and constitutional symptoms. She was treated with steroids, with tremendous improvement in her general well-being, resolution of lymphadenopathy and pleural effusion, and normalization of her hemoglobin and serum calcium. The atypical presentation of SLE with hypercalcemia with pleural effusion is discussed.
CONCLUSIONS: SLE should be one of the differential diagnoses in patients presenting with severe hypercalcemia.
KEYWORDS: atypical presentation; hypercalcemia; systemic lupus erythematosus

Matched MeSH terms: Pleural Effusion
Fulltext Transudative pleural effusion in a patient with pleural tuberculosis

Meryl Grace Lansing, Liew Sat Lin Constance, Chang Chee Keong, Pradip Subramaniam

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):97-97.
MyJurnal

Introduction:Light’s criteria for pleural fluid analysis has long been the standard for distinguishing transudates from exudates. In pleural tuberculosis, the resulting pleural fluids are usually exudates. We present a case of presumed transudative effusion which was eventually diagnosed as pleural tuberculosis. Case description: A 59-year-old man with end-stage renal failure (ESRF) on regular haemodialysis presented with a one-day history of acute onset dys-pnoea associated with pleuritic chest pain and cough. Chest radiograph revealed bilateral pleural effusions and thoracentesis was done. The pleural fluid result was interpreted as transudative effusion according to Light’s criteria because his pleural fluid to serum protein ratio was less than 0.5. AFB 1+ was seen in the pleural fluid with negative gram stain and culture. This resulted in conflicting opinions on whether to start this patient on anti-tuberculous ther-apy (ATT) and there was even a suggestion to get a second opinion for the possibility of AFB fluid contamination. The initial diagnosis was written as fluid overload secondary to ESRF but ATT was started anyway to cover for pleural TB. On further analysis of his pleural fluid, the pleural protein 32 g/L which on its own is a marker of exudative effusion. Subsequent investigations revealed the presence of exudative ascitic fluid which further raised the suspicion for a concomitant peritoneal TB. Conclusion: Premature conclusion that the pleural fluid was transudative occurred prob-ably due to the bilateral nature of the pleural effusion associated with a known tendency for the patient to develop pulmonary overload secondary to his ESRF. This case is a reminder that Light’s criteria also requires serum and fluid LDH measurement for the diagnosis of transudative pleural effusion. More importantly, a high level of suspicion for TB is important when evaluating patients from areas where TB is prevalent and a positive AFB result should not be taken lightly.

Matched MeSH terms: Pleural Effusion
Fulltext Invasive Pneumococcal Pneumonia with Massive Empyema: a case report

Tin Nwe Latt

Journal of Clinical and Health Sciences, 2016;1:41-47.

Although the use of appropriate antibiotics has significantly improved the outcome of pneumonia, severe complications are still encountered. We report here of a case with invasive pneumococcal pneumonia with massive empyema. A 2-year-4-month old girl presented with fever for 8 days and intermittent cough for 2 weeks. On examination, reduced air entry with dullness on percussion was noted on the left lung. Chest ultrasound revealed moderate to gross pleural effusion with septations, for which left thoraco-centesis with insertion of pigtail tube was performed. Streptococcus pneumoniae was detected via polymerase chain reaction (PCR) test in the pleural fluid. Intravenous (IV) benzylpenicillin and ceftriaxone were given together with one course (5 days) of intrapleural urokinase to breakdown the septations. Timely and appropriate management of pneumonia including the use of thrombolytic agent is vital to ensure optimal outcome and reduce the need of invasive procedures in cases with massive empyema. Public awareness of pneumococcal vaccination is also essential as a part of preventive measures.

Matched MeSH terms: Pleural Effusion

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