Tuberculous pleural effusions in HIV-infected patients
- Michael D Frye, MD
Michael D Frye, MD
- Associate Professor of Medicine
- Medical University of South Carolina
- John T Huggins, MD
John T Huggins, MD
- Associate Professor of Medicine
- Medical University of South Carolina
Among patients with tuberculosis (TB), pleural involvement appears to be more common in the presence of HIV coinfection. In one case-control study including 3000 patients with tuberculosis, the incidence of pleural involvement among patients with and without AIDS was 11 and 6 percent, respectively . It is unclear if the higher rate of pleural disease reflects a greater burden of pleural mycobacteria or dysregulation of immune function in the pleural space.
Tuberculous pleural effusion and tuberculous pleurisy are synonymous. Tuberculous pleural effusion is an exudative, lymphocyte-predominant pleural effusion that occurs as a result of a delayed hypersensitivity reaction to mycobacteria or mycobacterial antigens in the pleural space. Acid-fast bacilli (AFB) stains and AFB cultures are of low yield in the setting of tuberculous pleural effusions, and often pleural biopsy is needed to confirm the diagnosis. In contrast, tuberculous empyema is a chronic, suppurative infection due to the presence of a high burden of mycobacteria in the pleural space (image 1). When pleural fluid is aspirated in tuberculous empyema, it is grossly purulent and is always AFB smear and culture positive.
The characteristics, diagnosis, and treatment of tuberculous pleural effusions in HIV-infected patients will be reviewed here. The general features, diagnosis, and treatment of HIV-infected patients with tuberculosis and issues related to non–HIV-infected patients with tuberculous pleural effusion are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of tuberculosis in HIV-infected patients" and "Treatment of pulmonary tuberculosis in HIV-infected adults" and "Tuberculous pleural effusions in HIV-uninfected patients".)
In the United States, individuals with HIV and tuberculous pleural effusions are predominantly male and African American or Hispanic. They tend to be younger (33 to 38 years) than HIV-uninfected patients with tuberculous pleural effusions (47 years). HIV-infected patients with tuberculous pleural effusion have a longer duration of illness and lower incidence of chest pain. Systemic symptoms and signs such as night sweats, diarrhea, hepatosplenomegaly, and lymphadenopathy are more common in HIV-infected patients. The pleural fluid is much more likely to be smear and culture positive for mycobacteria. If the CD4 count is less than 100 cells/mm3, roughly 50 percent will have a positive smear for acid-fast bacilli (AFB) [2,3].
Affected patients generally present with the following findings [4-6]:
- Frye MD, Pozsik CJ, Sahn SA. Tuberculous pleurisy is more common in AIDS than in non-AIDS patients with tuberculosis. Chest 1997; 112:393.
- Heyderman RS, Makunike R, Muza T, et al. Pleural tuberculosis in Harare, Zimbabwe: the relationship between human immunodeficiency virus, CD4 lymphocyte count, granuloma formation and disseminated disease. Trop Med Int Health 1998; 3:14.
- Richter C, Perenboom R, Mtoni I, et al. Clinical features of HIV-seropositive and HIV-seronegative patients with tuberculous pleural effusion in Dar es Salaam, Tanzania. Chest 1994; 106:1471.
- Kitinya JN, Richter C, Perenboom R, et al. Influence of HIV status on pathological changes in tuberculous pleuritis. Tuber Lung Dis 1994; 75:195.
- Relkin F, Aranda CP, Garay SM, et al. Pleural tuberculosis and HIV infection. Chest 1994; 105:1338.
- Frye MD, Pozsik CJ, Sahn SA. Tuberculous pleuritis and HIV disease. Chest 1995; 108:102S.
- Havlir DV, Barnes PF. Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 1999; 340:367.
- Daley CL, Small PM, Schecter GF, et al. An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. An analysis using restriction-fragment-length polymorphisms. N Engl J Med 1992; 326:231.
- Tshibwabwa-Tumba E, Mwinga A, Pobee JO, Zumla A. Radiological features of pulmonary tuberculosis in 963 HIV-infected adults at three Central African Hospitals. Clin Radiol 1997; 52:837.
- Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med 2000; 161:1376.
- Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2016.
- Baba K, Hoosen AA, Langeland N, Dyrhol-Riise AM. Adenosine deaminase activity is a sensitive marker for the diagnosis of tuberculous pleuritis in patients with very low CD4 counts. PLoS One 2008; 3:e2788.
- Zhou Q, Chen YQ, Qin SM, et al. Diagnostic accuracy of T-cell interferon-γ release assays in tuberculous pleurisy: a meta-analysis. Respirology 2011; 16:473.
- Riantawan P, Chaowalit P, Wongsangiem M, Rojanaraweewong P. Diagnostic value of pleural fluid adenosine deaminase in tuberculous pleuritis with reference to HIV coinfection and a Bayesian analysis. Chest 1999; 116:97.
- Gil V, Cordero PJ, Greses JV, Soler JJ. Pleural tuberculosis in HIV-infected patients. Chest 1995; 107:1775.
- Aljohaney A, Amjadi K, Alvarez GG. A systematic review of the epidemiology, immunopathogenesis, diagnosis, and treatment of pleural TB in HIV-infected patients. Clin Dev Immunol 2012; 2012:842045.
- Conde MB, Loivos AC, Rezende VM, et al. Yield of sputum induction in the diagnosis of pleural tuberculosis. Am J Respir Crit Care Med 2003; 167:723.
- Light RW. Update on tuberculous pleural effusion. Respirology 2010; 15:451.
- Engel ME, Matchaba PT, Volmink J. Corticosteroids for tuberculous pleurisy. Cochrane Database Syst Rev 2007; :CD001876.
- Elliott AM, Luzze H, Quigley MA, et al. A randomized, double-blind, placebo-controlled trial of the use of prednisolone as an adjunct to treatment in HIV-1-associated pleural tuberculosis. J Infect Dis 2004; 190:869.
- Burman WJ, Jones BE. Treatment of HIV-related tuberculosis in the era of effective antiretroviral therapy. Am J Respir Crit Care Med 2001; 164:7.
- Dean GL, Edwards SG, Ives NJ, et al. Treatment of tuberculosis in HIV-infected persons in the era of highly active antiretroviral therapy. AIDS 2002; 16:75.
- Dheda K, Lampe FC, Johnson MA, Lipman MC. Outcome of HIV-associated tuberculosis in the era of highly active antiretroviral therapy. J Infect Dis 2004; 190:1670.
- Lawn SD, Myer L, Bekker LG, Wood R. Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa. AIDS 2007; 21:335.
- Lai YF, Chao TY, Wang YH, Lin AS. Pigtail drainage in the treatment of tuberculous pleural effusions: a randomised study. Thorax 2003; 58:149.
- Bhuniya S, Arunabha DC, Choudhury S, et al. Role of therapeutic thoracentesis in tuberculous pleural effusion. Ann Thorac Med 2012; 7:215.
- Bolliger CT, de Kock MA. Influence of a fibrothorax on the flow/volume curve. Respiration 1988; 54:197.
- Candela A, Andujar J, Hernández L, et al. Functional sequelae of tuberculous pleurisy in patients correctly treated. Chest 2003; 123:1996.