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]:
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