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Diagnostic tools in tuberculous pleurisy: a direct comparative study

¹ Institutes of Internal Medicine, ² Anatomical Pathology, and ³ Medical Biochemistry, University of Stellenbosch Medical School, Tyberberg Hospital, Cape Town, South Africa

CORRESPONDENCE: A.H. Diacon, Dept of Internal Medicine, University of Stellenbosch Medical School, PO Box 19063, 7505, Tygerberg, Cape Town, South Africa. Fax: 27 219317442. E-mail: ahd@sun.ac.za

Keywords: closed needle biopsy, pleural effusion, thoracoscopy, tuberculosis

Received: February 14, 2003
Accepted April 25, 2003

This study was supported by the Tuberculosis Fund, University of Stellenbosch, Cape Town, South Africa. A.H. Diacon was partly supported by the local Respiratory Research Unit Fund and a post­doctoral research fellowship from the University of Stellenbosch.

Thoracoscopy is the most accurate yet most expensive tool for establishing the diagnosis of tuberculous (TB) pleurisy. However, most high TB-incidence regions have limited financial resources, lack the infrastructure needed for routine thoracoscopy and require an alternative, cost­effective diagnostic approach for pleural effusions.

Altogether, 51 patients with undiagnosed exudative pleural effusions were recruited for a prospective, direct comparison between bronchial wash, pleural fluid microbiology and biochemistry (adenosine deaminase (ADA) and cell count), closed needle biopsy, and medical thoracoscopy.

The final diagnosis was TB in 42 patients (82%), malignancy in five (10%) and idiopathic in four patients (8%). Sensitivity of histology, culture and combined histology/culture was 66, 48 and 79%, respectively for closed needle biopsy and 100, 76 and 100%, respectively for thoracoscopy. Both were 100% specific. Pleural fluid ADA of 50 U·L^–1 was 95% sensitive and 89% specific. Combined ADA, lymphocyte/neutrophil ratio 0.75 plus closed needle biopsy reached 93% sensitivity and 100% specificity.

A combination of pleural fluid adenosine deaminase, differential cell count and closed needle biopsy has a high diagnostic accuracy in undiagnosed exudative pleural effusions in areas with high incidences of tuberculosis and might substitute medical thoracoscopy at considerably lower expense in resource­poor countries.

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