Tuberculous Pleurisy Is More Common in AIDS Than in Non-AIDS Patients With Tuberculosis

doi:10.1378/chest.112.2.393

Chest

Volume 112, Issue 2, August 1997, Pages 393-397

https://doi.org/10.1378/chest.112.2.393 Get rights and content

Objective

To investigate the incidence, clinical features, and treatment of tuberculous pleurisy in AIDS patients.

Methods

We reviewed all cases of pleural tuberculosis in AIDS patients in South Carolina from 1988 through 1994. Clinical findings, test results, treatment, and outcome were analyzed.

Main results

Twenty-two (11%) of the 202 AIDS patients with tuberculosis had pleural involvement compared to 6% (169/2,817) pleural involvement in non-AIDS patients (p=0.01). Associated features of AIDS tuberculous pleurisy included substantial weight loss (7.65±1.35 kg) and lower lobe infiltrates (12/22; 55%). No difference in pleural fluid characteristics was found when comparing AIDS patients with a serum CD4 count ≥200/µL to patients with CD4 count <200/µL. Two (9%) of the 22 patients died of tuberculosis. Chest radiograph follow-up of 20 patients showed complete resolution in 7, improvement in 10, and no improvement in 3.

Conclusions

In South Carolina, pleural involvement is more common in AIDS patients than in non-AIDS patients with tuberculosis. Tuberculous pleurisy has several atypical features in AIDS patients such as substantial weight loss and lower lobe infiltrates. The outcome of treatment is good for most patients.

Section snippets

Materials and Methods

We identified all cases of pleural tuberculosis in South Carolina from 1988 through 1994 by reviewing the state tuberculosis registry. From this group, we identified those patients who were also HIV positive. All patients with tuberculosis are routinely offered HIV testing. Case information was obtained from the treating physicians and by review of the records. Patient confidentiality was maintained. These cases were reviewed retrospectively for clinical findings, test results, treatment, and

Results

From 1988 through 1994, there were 2,817 cases of tuberculosis in non-AIDS patients in South Carolina. Pleural involvement was diagnosed in 169 of 2,817 (6%) cases. There were 202 AIDS patients with tuberculosis. Twenty-two of 202 (11%) of the AIDS patients with tuberculosis had pleural involvement compared to 6% pleural involvement in non-AIDS patients (p=0.01). There were 19 definite cases and three probable cases of AIDS tuberculous pleuritis. During this time, there were 4,552 newly

Discussion

Among all patients with tuberculosis in South Carolina, the proportion with pleural involvement is greater in AIDS patients than in non-AIDS patients. This is an unexpected finding given the currently accepted pathophysiologic state of the disease. Since tuberculous pleurisy is thought to be primarily an immune reaction to tuberculin proteins in the pleural space, a lower incidence in AIDS patients because of impaired cell-mediated immunity would be expected. There are several possible

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Cited by (55)

Tuberculous pleural effusion
2014, Archivos de Bronconeumologia
Tuberculous pleural effusion (TBPE) is the most common form of extrapulmonary tuberculosis (TB) in Spain, and is one of the most frequent causes of pleural effusion. Although the incidence has steadily declined (4.8 cases/100 000 population in 2009), the percentage of TBPE remains steady with respect to the total number of TB cases (14.3%–19.3%). Almost two thirds are men, more than 60% are aged between 15 and 44 years, and it is more common in patients with human immunodeficiency virus. The pathogenesis is usually a delayed hypersensitivity reaction. Symptoms vary depending on the population (more acute in young people and more prolonged in the elderly). The effusion is almost invariably a unilateral exudate (according to Light's criteria), more often on the right side, and the tuberculin test is negative in one third of cases.
There are limitations in making a definitive diagnosis, so various pleural fluid biomarkers have been used for this. The combination of adenosine deaminase and lymphocyte percentage may be useful in this respect. Treatment is the same as for any TB. The addition of corticosteroids is not advisable, and chest drainage could help to improve symptoms more rapidly in large effusions.
El derrame pleural tuberculoso (DPTB) es la causa más frecuente de tuberculosis (TB) extrapulmonar en nuestro país y uno de los motivos más habituales de derrame pleural. Si bien la incidencia disminuye progresivamente (4,8 casos/100.000 habitantes en el año 2009), el porcentaje de DPTB se mantiene estable con respecto al número de casos totales de TB (14,3-19,3%). Casi las dos terceras partes son hombres, más del 60% tienen edades entre los 15-44 años y es más frecuente en los pacientes infectados por el virus de la inmunodeficiencia humana. La patogenia suele ser una reacción de hipersensibilidad retardada. La clínica varía dependiendo de la población (más aguda en los jóvenes y más prolongada en los ancianos). El derrame es casi invariablemente un exudado unilateral (según los criterios de Light), más frecuentemente del lado derecho, y la prueba de la tuberculina es negativa en la tercera parte de los casos.
Los diagnósticos de certeza tienen limitaciones, por lo que para ello se han utilizado diversos biomarcadores en el líquido pleural. La asociación de la adenosina desaminasa y del porcentaje de linfocitos puede ser útil para el diagnóstico. El tratamiento es el de cualquier TB. No parece recomendable añadir corticoides y el drenaje torácico podría contribuir, en los grandes derrames, a una mejoría más rápida de los síntomas.
Recent epidemiological trends in tuberculous pleural effusion in Galicia, Spain
2012, European Journal of Internal Medicine
Citation Excerpt :
In Galicia, 44% of the TB is extrapulmonary, and the DPTB are the most frequent cause [14]. At an international level, DPTB is considered the second cause of extrapulmonary TB (behind that of TB adenitis) [15], and the reviews on its epidemiology are focused on the influence that HIV infection may have on this form of TB presentation [16–18]. The aim of the present study is to determine the recent epidemiological trends of TBPE in Galicia, and to analyse the impact of the introduction of the GPCP for TB in our region.
Knowledge on the distribution and determinants of tuberculous pleural effusions (TBPE) is incomplete. We aimed to describe the epidemiological trends and individual characteristics of TBPE in Galicia, Spain, over a 10-year period (2000–2009).
A retrospective, observational study based on epidemiological data obtained from the Galician Tuberculosis Register.
There were 1835 cases of TBPE (16.3% of the total 11,241 TB cases reported). The number and incidence of TBPE decreased significantly during the study period, from (262 and 9.6/100,000 inhabitants in 2000, to 133 and 4.8 in 2009, respectively; P < .001 for both). The mean annual decrease in TBPE incidence was 6.9%, and 50% overall. TBPE mainly affected males (63.5%), precisely 61.2% young males between 15 and 44 years. Twenty-five percent had lung involvement (chest X-ray), and 41.7% had a positive sputum culture. A significant increase (P < .001) was observed during the study in the percentage of patients who had more TB risk factors.
The incidence of TBPE decreased significantly during the study period, with no changes in epidemiological characteristics, and with trends similar to the total number of TB cases. The introduction of the Galician Prevention and Control Plan (GPCP) for tuberculosis appears to be effective for better control of TB.
Multidrug resistant tuberculosis diagnosed by synovial fluid analysis
2012, Revista Portuguesa de Pneumologia
A tuberculose constitui um importante problema de saúde pública mundial. A co-infeção pelo HIV contribui para o aumento da incidência da doença e em particular a causada por estirpes de Mycobacterium tuberculosis (MT) multirresistentes. Os autores descrevem um doente HIV-positivo com tuberculose pleural e ganglionar diagnosticada pelas características bioquímicas do líquido pleural e resultados anatomo-patológicos de biopsias, mas sem identificação do agente, que posteriormente apresentou envolvimento do joelho. A artrocentese do joelho permitiu o isolamento do MT e a realização de teste de sensibilidade, possibilitando o diagnóstico de tuberculose multirresistente e a instituição de um esquema terapêutico adequado.
A identificação do MT e a realização de testes de sensibilidade são muito importantes, especialmente em doentes com co-infecção por HIV.
Tuberculosis remains a major public health problem worldwide. HIV co-infection is contributing to an increased incidence of the disease, particularly that caused by multidrug resistant strains of Mycobacterium tuberculosis (MT). We describe an HIV-infected patient with pleural and lymph node tuberculosis diagnosed by pleural effusion characteristics and biopsy specimens, without MT identification, that further presented with knee-joint involvement. Arthrocentesis allowed MT isolation and drug susceptibility testing, resulting in a diagnosis of multidrug-resistant tuberculosis and an appropriate treatment regimen.
MT identification and drug susceptibility tests are very important, especially for HIV co-infected patients.
Tuberculosis and Atypical Mycobacterial Infections
2011, Tropical Infectious Diseases: Principles, Pathogens and Practice
Evaluation of real-time polymerase chain reaction, interferon-gamma, adenosine deaminase, and immunoglobulin A for the efficient diagnosis of pleural tuberculosis
2011, International Journal of Infectious Diseases
Citation Excerpt :
Globally, the proportion of extrapulmonary TB (EPTB) cases reported from various countries ranges from 15% to 25%,2 with greater proportions occurring in countries with a high prevalence of human immunodeficiency virus (HIV) infection.3 Pleural TB is a common manifestation of EPTB; it constitutes a frequent clinical problem4 and is particularly important in the present era of co-infection with HIV.5 Pleural TB accounts for 3.3–4.0% of TB cases in the USA.6
Pleural tuberculosis (TB) is a diagnostic challenge because of its non-specific clinical presentation and paucibacillary nature. Conventional diagnosis methods have limitations. We evaluated the real-time polymerase chain reaction (PCR), interferon-gamma (IFN-γ), adenosine deaminase (ADA), and immunoglobulin A (IgA).
We assessed 204 cases: 50 were confirmed pleural TB, 104 were probable pleural TB, and 50 formed the non-TB group. IFN-γ and IgA were measured by enzyme-linked immunosorbent assay and ADA was measured by colorimetric assay. Real-time PCR was carried out using the 16S rRNA sequence, pleural biopsy specimens were submitted to histopathologic examination, pleural fluid culture was undertaken using Lowenstein–Jensen and MGIT-BACTEC, and pleural fluid smears were stained with auramine O.
For confirmed and probable pleural TB cases, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was highest for IFN-γ (0.994 and 0.963, respectively), followed by ADA (0.989 and 0.945, respectively), real-time PCR (0.898 and 0.784, respectively), and IgA (0.817 and 0.784, respectively). For confirmed and probable pleural TB cases, IFN-γ showed the highest sensitivity (98% and 76.9%, respectively), followed by ADA (92% and 73%, respectively), real-time PCR (80% and 57.7%, respectively), and IgA (70% and 57.7%, respectively). With regard to combined positivity, the combination of ‘either real-time PCR or IFN-γ’ showed the highest sensitivity: 100% in confirmed pleural TB and 96.2% in probable pleural TB.
IFN-γ showed the highest sensitivity as an individual diagnostic test. When a combination of tests was used, positivity of ‘either IFN-γ or real-time PCR’ appeared valuable for the diagnosis of pleural TB.
Tuberculosis and Atypical Mycobacterial Infections
2011, Tropical Infectious Diseases

View all citing articles on Scopus

: Presented in part at the Annual Scientific Session of the American College of Chest Physicians, New York, October 30, 1995.

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Chest

Tuberculous Pleurisy Is More Common in AIDS Than in Non-AIDS Patients With Tuberculosis

Objective

Methods

Main results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

Chest

Chest

Chest

Tuber Lung Dis

Lancet

Chest

Pleural effusion, tuberculosis and HIV-1 infection in Kigali, Rwanda

AIDS

Pleural effusions in hospitalized patients with AIDS

Ann Intern Med

Causes of pleural effusion in 75 HIV-infected patients [letter]

Chest

A retrospective analysis of pleural effusion in human immunodeficiency virus infected patients [abstract]

Chest