Tuberculous pleural effusions in HIV-uninfected 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
Tuberculous pleural effusion accounts for approximately 5 percent of disease due to Mycobacterium tuberculosis and is the second most common form of extrapulmonary tuberculosis (TB) after lymphatic involvement [1,2]. Tuberculous pleural effusion is synonymous with the term tuberculous pleurisy.
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 Mycobacterium burden 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.
Issues related to the diagnosis and treatment of tuberculous pleural effusions in HIV-uninfected patients will be reviewed here. Issues related to tuberculous pleural effusions in HIV-infected patients are discussed separately. (See "Tuberculous pleural effusions in HIV-infected patients".)
Tuberculous pleural effusions are thought to result from a delayed hypersensitivity reaction to mycobacteria and mycobacterial antigens in the pleural space . These organisms and/or their antigens probably enter the pleural space due to leakage or rupture of a subpleural focus of disease. In one study of 24 patients with tuberculous pleural effusions who underwent thoracotomy, for example, a caseous focus in the lung contiguous with the diseased pleura was found in half of cases . Development of pleural effusion occurs largely as a result of hypersensitivity reaction, but tuberculous pleurisy must be considered to be due to active disease since culture of the fluid grows mycobacteria in some cases and culture of the pleural tissue usually grows mycobacteria. Tuberculous pleural effusions are usually self-limited and resolve spontaneously with or without treatment in most cases. However, the condition can potentially progress and worsen and become a tuberculous empyema.
A tuberculous empyema represents chronic active disease involving the pleural space and can occur in the setting of a large pleural effusion that progresses, usually leading to an unexpandable lung . Simple tuberculous pleural effusion and tuberculous empyema can be considered a continuum of the same process. Tuberculous empyema can also develop via extension of infection from thoracic lymph nodes or subdiaphragmatic focus, via hematogenous spread, or in the setting of therapeutic pneumothorax therapy leading to an unexpandable lung.
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