Tuberculous Pleurisy

doi:10.1378/chest.63.1.88

Chest

Volume 63, Issue 1, January 1973, Pages 88-92

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The average age of patients with tuberculous pleurisy is increasing and the disease is now commonly seen in middle and old age. Abrupt onset occurs in two-thirds of cases and may resemble acute bacterial pneumonia. The temperature may not be elevated above normal in occasional patients when they are first examined. Initial intermediate strength tuberculin or tine tests are negative in almost one-third of patients but upon repeat of these tests or performance of second strength tests a positive reaction is invariably obtained. The pleural effusion is usually unilateral, most commonly less than one-half the volume of the hemithorax but may involve the entire hemithorax, and is associated with active pulmonary lesions in slightly more than one-third of the cases. Pleural fluid lymphocytosis of 95-100 percent is found in most cases but is a nonspecific finding. Serosanguinous fluid is rarely present Pleural fluid protein is almost invariably above 3 gm/100 ml and LDH levels are usually elevated. The frequency of diminished pleural fluid glucose has been overemphasized in the previous literature. Less than one-fifth of patients have values below 50 mg/100 ml but none has had a level less than 30 mg/100 ml in our series of cases. Pleural biopsy histologic examination and pleural biopsy culture for tuberculous organisms are each positive in more than two-thirds of patients. Pleural fluid culture demonstrates tubercle bacilli less frequently than biopsy culture and sputum or gastric cultures are usually negative unless pulmonary lesions are present. Treatment for two years with isoniazid and ethambutol or with isoniazid and para-aminosalicylic acid produces excellent results and development of new pulmonary lesions, recurrence of pleural effusion, or a need for pleural decortication are very rare.

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PATHOGENESIS

Tuberculous pleurisy denotes inflammatory disease of the pleura due to Mycobacterium tuberculosis. Usually an unexplained pleural effusion first suggests the diagnosis; however, a pleural effusion is not always clinically recognized. The disease is thought to result from rupture of a subpleural caseous focus in the lung into the pleural space.²,³ The pulmonary focus has been frequently recognized when performing open pleural biopsy.² Hypersensitivity to the tubercle bacillus also plays an

CLINICAL FEATURES

Previously, tuberculous pleurisy was found almost exclusively in young adults. The average age in Sibley's⁵ series of cases was 25 years. Twenty of our 49 patients were more than 35 years old, including seven more than 70 years of age. The increasing age of patients with tuberculous pleurisy creates diagnostic difficulties since malignancy, congestive heart failure, pneumonia, and pulmonary infarction are common problems in older patients.

The onset may be either abrupt or insidious. In 31

TUBERCULIN TESTS

Although it was formerly observed that almost all patients with active tuberculosis have positive intermediate strength tuberculin skin tests, more recent reports stress the frequent occurrence of negative results.⁷,⁸ Eleven out of 36 patients had negative purified protein derivative (PPD) intermediate and two out of six patients had negative tine tests when first studied (31 percent), but all had positive reactions when re-evaluated with the above tests or with second strength PPD tests. Falk⁹

ROENTGENOGRAPHIC FINDINGS

In our cases the pleural effusion occurred on the right side in 28 patients, on the left in 19, and bilaterally in two patients. Sibley⁵ also noted a greater frequency of right-sided effusions, but had 10 percent bilateral effusions in his series. The effusion occupied less than one-half the hemithorax in 39 of our patients. Two patients had effusions which completely filled the hemithorax and are included in a group of massive pleural effusions not due to malignancy.¹¹ In untreated patients

PLEURAL FLUID

The pleural fluid white blood cell count was between 1,000 and 6,000/cu mm in 23 out of 41 patients. Twenty-eight out of 42 patients (67 percent) showed values of more than 95 percent lymphocytes and only five patients (12 percent) had less than 50 percent lymphocytes on the initial determination. The finding of 95 to 100 percent lymphocytes is not specific for tuberculosis, but is also frequently seen in carcinoma, lymphoma, and in chronic effusions of many causes.¹² As is well known, serial

PLEURAL FLUID GLUCOSE

Earlier reports mention the frequency of diminished glucose concentration in tuberculous effusions. Calnan et al¹⁷ found a glucose concentration less than 60 mg/100 ml in 13 out of 25 cases including seven with less than 30 mg/100 ml. Gelenger and Wiggers¹⁸ reported values below 39.5 mg/100 ml in ten cases, with an average value of 15.7 mg/100 ml. They stated that a pleural glucose concentration of 30 mg/100 ml or less was diagnostic of tuberculosis and that the diagnosis of tuberculosis was

PLEURAL BIOPSY FINDINGS

Results of needle pleural biopsy have been reported positive in 50-80 percent of cases of tuberculous pleurisy.22, 23, 24 Usually a biopsy demonstrating either caseating or noncaseating epithelioid granulomas is accepted as tuberculous although only identification of acid-fast bacilli or culture of tubercle bacilli from the specimen is completely diagnostic.²⁵ We used the Abrams needle in all but a few early cases and found it to give more satisfactory results than the Vim-Silverman needle. The

PLEURAL FLUID CULTURE

Cultures of the pleural fluid revealed tubercle bacilli in 11 out of 45 cases (24 percent) including three with negative results of biopsies. Sibley⁵ reported positive cultures in 70 percent of his cases, although in most other series positive results are found in less than 30 percent of cases.⁹ The percentage of positive cultures has been increased by centrifuging large volumes of pleural fluid (100-500 ml), performing multiple cultures, and by inoculation into guinea pigs.⁵,¹⁹ Our recent

TREATMENT

We treated our patients 24 months with a two-drug regimen, isoniazid (INH), para-aminosalicylic acid (PAS), at the beginning of the study, and INH-ethambutol since 1967 with equally good results. (Doses: INH 300 mg daily, PAS 12 gm daily, ethambutol 15 mg/kg daily). The PAS or ethambutol therapy was usually discontinued after 12 to 18 months. We did not employ either a three-drug or one-drug regimen initially in any patients. The pleural effusion partially or completely cleared within a few

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