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Pleural TB

Pleural TB. Case 2. 33y Male Smoker (10 pack) Aboriginal 1 Month Cough, SOBE ,Fever Cough non productive No orthopnea , PND , LL swelling Fever intermittent ,night sweating Wt loss 12 lbs , decrease appetite. History. Lives in reserve No Contact with TB No travel ,pets PMH –ve

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Pleural TB

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  1. Pleural TB

  2. Case 2 • 33y Male Smoker (10 pack) Aboriginal • 1 Month Cough, SOBE ,Fever • Cough non productive • No orthopnea , PND , LL swelling • Fever intermittent ,night sweating • Wt loss 12 lbs , decrease appetite

  3. History • Lives in reserve • No Contact with TB • No travel ,pets • PMH –ve • PSH : MVA Rt arm atrophy 1991 • Blood Tx after MVA • No IV drugs

  4. Examination • Temp 39.8 BP 120/65 HR 80 • RR 16 Sat 93% RA • No enlarged LN • Chest : decreased BS Lt lower 2/3 Post Dull percussion note • CNS : Rt Arm weakness 3/5 distal > proximal • Abd & LL Unremarkable

  5. Investigation • CBC N • Creat , BUN , Lytes N • LFT & Liver enzymes N • CXR

  6. Investigation • Sputum GS & C/S -ve • Sputum AFB –ve 3 times • PPD +ve 18 mm • VATS  Pleura Thickened with adhesions 1500 Pleural fluid drained Pleural lysis Pleural Bx  Granuloma with +ve DNA For Mycobacterium

  7. Management • 4 Anti TB Rx + Pyridoxine • Improved afebrile ,no SOB • Chest tube was removed • Discharged Home

  8. TB Pleural Effusion • 5% of all diseases attributed to TB • Results from delayed hypersensitivity reaction to TB antigen • Different from tuberculous empyema which is purulent fluid abundant in TB organism with thickened calcified pleura • Different presentation in Non HIV Vs HIV

  9. Presentation 60 Pt study *In Non HIV • Non productive Cough ,Pleuritic CP , SOB • Fever ,Night sweating & Wt Loss * In HIV Younger Patient , more Wt Loss & extrapulmonary involvement Frye et al Chest Aug 1997

  10. Imaging *In Non HIV 70 Pleural TB/1700 Dx TB patient • Unilateral effusion • Associated Lung infiltrates 50% Upper Lobes 75%  Reactivation Lower lobes 25%  Primary Disease Seibert et al Chest April 1991

  11. Imaging In HIV 963 HIV Vs 1000 Non HIV • Unilateral effusion • Lung infiltrate Lower Lobes • Adenopathy 5-18% • Miliary Pattern 7-10% • Less cavitations 33% Tshibwabwa-Tumba et al Clin Radiol 1997 Nov

  12. PPD Skin Test • 70 Patients 43 HIV & 27 Non HIV • HIV mainly IVDU • Non HIV 73% +ve Vs 41% HIV • Age Non HIV 52 Vs 37 HIV Relkin et al Chest may 1994

  13. Microbiology • Sputum culture +ve 20-50%  involvement of lung parenchyma • Pleural Fluid culture +ve 40-50 % • Pleural Bx culture +ve 60-80 % • Higher yield in HIV patients in all specimens

  14. ADA • 216 Patients 100 TB , 86 Malignancy 19 empyema , 6 transudate 15 miscellaneous , 8 unknown • High ADA in TB 110 & in Empyema 191 No difference Between HIV +ve & -ve TB Pt • Cut off 60 u/l  PPV & NPV 95% Riantawan P et al Chest 1999 Jul

  15. ADA • 106 lymphocytic effusion {Non TB} • ADA measured once in all & second time 6weeks later in 26 cases • 45 Post CABG , 27 Malignant 10 Miscellaneous , 24 Transudative • With cut off 40 u/l only 3 patients +ve 2 Lymphoma & 1 complicated parapneumonic • High NPV & reproducible Gary Lee et al Chest Aug 2001

  16. ADA ,PCR & Interferon Gamma • 140 Patient had ADA , PCR & INF pleural fluid levels • 42 Confirmed TB (+ve fluid smear or culture or +ve histology) • 19 Probable TB Symptoms or signs , Bx chronic inflammation +ve sputum or Response to Anti TB • 70 Non TB etiology , 9 Unknown Villegas Chest, Nov 2000

  17. Treatment • Similar to Pulmonary TB • Steroid ? Effect small study 40 pt faster resolution of Fever & SOB & effusion But no effect on pleural thickening • Drainage Small study 60 pt Initial improvement in SOB in first week No effect later on symptoms or pleural thickening

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