Tuberculous empyema

Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions

Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.

Clinicopathological outcome in 27 children with tuberculous empyema in Shandong Provincial Chest Hospital, Jinan, China

The literature on childhood tuberculous empyema (TE) is limited. The aim of this study was to examine the clinicopathological characteristics and outcome of paediatric TE and methods of prompt diagnosis and treatment. Between January 2014 and April 2019, 27 consecutive patients with TE aged ≤15 years [mean (SD) 12.2 (3.3), range 6-15] were retrospectively reviewed. The following were reviewed: baseline demographics, symptoms, laboratory and pathological examination, radiographical findings, microbiological data, anti-tuberculous and surgical treatment and clinical outcome. Acid-fast bacillus (AFB) smear, culture, TB real-time (RT) polymerase chain reaction (PCR) and T-SPOT.TB assay were reviewed. Six (60%) of 10 patients were TB-RT-PCR-positive in pus or purulent fluid. Twenty-three of 24 (95.8%) were T-SPOT.TB-positive. Decortication by surgical thoracotomy or thoracoscopy was performed in 22 (81.5%) patients. None of the 27 patients had specific complications such as pyopneumothorax or bronchopleural fistula and all were successfully treated. In childhood TE, aggressive surgical management is associated with a favourable outcome.Abbreviations: AFB, acid-fast bacilli; E, ethambutol; EPTB, extra-pulmonary TB; H, isoniazid; HIC, high-income countries; LMIC, low- and middle-income countries; MTB, Mycobacterium tuberculosis; PCR, polymerase chain reaction; PTB, pulmonary TB; R, rifampicin; RT, real time; TB, tuberculosis; TE, tuberculous empyema; Z, pyrazinamide.

Comparison of outcome of surgery for tubercular and nontubercular empyema: An analysis of 285 consecutive cases

Background

Few studies have compared the surgical outcomes between tubercular empyema (TE) and nontubercular empyema (NTE), which were limited by a small sample size. We conducted this study with the objective of comparing the surgical outcomes of patients with tuberculous and nontuberculous empyema.

Materials and Methods

This is a retrospective analysis of 285 consecutively operated cases of TE and NTE over 5 years conducted in a tertiary care center in New Delhi, India. A comparative analysis of demography, intraoperative, and postoperative variables including mortality between the two groups was carried out.

Results

Out of 285 patients, 166 were tubercular and 119 were nontubercular. Nontubercular group had significantly higher age (45.4 ± 17.2 vs. 31.2 ± 13.6 in years), more comorbidities. Procedure was started by thoracotomy in 25.9% of tubercular group and 41.1% of nontubercular group. In patients where procedure started by video-assisted thoracoscopic surgery (VATS), complete decortication could be achieved by VATS in 91.1% of TE patients, whereas it was possible in 77.2% of nontubercular group. Need for postoperative ventilation (10% vs. 1.2%, P = 0.0011) and intensive care unit (ICU) stay (25.2% vs. 3%, P = 0.001) was significantly higher in nontubercular group. Nontubercular group was found to have significantly higher number of complications (13.4% vs. 5.4%, P = 0.02) and postoperative mortality (10% vs. 0, P = 0.001).

Conclusions

Higher percentage of TE cases were managed by VATS with reduced operative time, less blood loss, and lower conversions. Need for postoperative ventilation, ICU stay, and complications including mortality were more in NTE.

Comparison of pediatric empyema secondary to tuberculosis or non-tuberculosis community-acquired pneumonia in those who underwent surgery in high TB burden areas

INTRODUCTION

Tuberculous empyema (TE) in children is common in high-TB burden and medical resource-limited areas. However, studies that evaluate the characteristics of TE in children are sparse. This study aimed to analyze the clinical features of pediatric TE receiving surgical intervention.

METHODS

We performed a retrospective study of children with empyema secondary to community-acquired pneumonia who underwent surgery in our institution. The clinical characteristics were compared between TE and empyema secondary non-tuberculosis infection (non-tuberculosis empyema, NTE).

RESULTS

One hundred patients were included (27 with TE and 73 with NTE). Stage 3 empyema occupied 81.5% and 45.2% of TE and NTE in this study. The TE children had older age, longer duration of illness, and milder symptoms. Pleural fluid culture was positive for Mycobacterium tuberculosis in 7.4% of patients with TE. Lymph node enlargement, lymph node calcification, and pleural nodules presented in TE with high specificity (93.2%, 98.6%, and 98.5%) but low sensitivity (33.3%, 14.8%, and 29.6%) on CT scan. Thoracoscopy surgery was performed in 14 (51.9%) in TE and 39 (53.4%) in NTE. Postoperative chest-tube indwelling time was longer (7.85 ± 5.00 vs. 4.89 ± 1.81 days, p < .001), and more patients had incomplete lung expansion after 3 months in TE.

CONCLUSION

Tuberculosis infection should be screened in management of children with empyema in high-TB burden areas. Pediatric TE usually presented at older age and with milder respiratory symptoms. Pleural biopsy during surgery is often necessary to confirm the cause of infection. Thoracotomy is still required in some pediatric TE or NTE with delayed treatment in medical resource-limited area.

Chronic tuberculous empyema in an 8-year-old boy

Mycobacterium tuberculosis (MTB) as a causative organism of empyema thoracis is rare, especially in children. An 8-year-old boy with tuberculous empyema and no history of contact with tuberculosis presented with minimal symptoms other than mild deformity of the chest wall. He had been vaccinated with bacillus Calmette-Guérin. A chest CT scan demonstrated intrathoracic lymphadenopathy, thickened and calcified pleural rind and rib thickening adjacent to the empyema. The diagnosis was confirmed by post-operative histopathological examination, positive acid-fast stains and DNA PCR. In countries with a high burden of tuberculosis, MTB should be considered in the differential diagnosis of empyema despite minimal symptoms.

Triple Cultures Increase the Diagnostic Sensitivity of Mycobacterial Tuberculosis Empyema

BACKGROUND

There is a continuous debate on the appropriate diagnostic approach and surgical management of mycobacterial empyema, with widely varied diagnostic practices and surgical outcomes. The aim of this study is to highlight the diagnostic approach and clinical features of patients who required surgical intervention for mycobacterial empyema.

METHODS

We performed a 5-year retrospective cohort study of all patients with mycobacterial empyema requiring surgery in a single institution from November 2009 to November 2014.

RESULTS

Eighteen patients (15 males and 3 females, median age 48.5 years) required surgery. Seventeen patients required decortication via posterolateral thoracotomy and one patient underwent video-assisted thoracic surgery drainage and pleural debridement. Prolonged air leak was the commonest surgical complication (50%, n = 9). 94.4% (n = 17) had necrotizing granulomatous inflammation on histological examination. The sensitivity of mycobacterium smear and culture ranged between 12.5% and 75% for pleural tissue, sputum, and pleural fluid individually. The combination of all 3 samples increased the diagnostic yield to 100%.

CONCLUSION

With the implementation of pleural tissue culture at surgery, the novel combination of sputum, pleural fluid, and pleural tissue culture provides excellent diagnostic yield.

Pleuritis Caused by Mycobacterium kyorinense without Pulmonary Involvement

We herein describe the first known case of pleuritis caused by Mycobacterium kyorinense without pulmonary involvement. A 48-year-old man undergoing immunosuppressant therapy presented with cough and dyspnea. An accumulation of pleural fluid was noted; however, computed tomography revealed no pulmonary lesions. Cultures of the fluid yielded non-tuberculous mycobacteria, which was identified as Mycobacterium kyorinense. The patient recovered after 6 months of therapy with clarithromycin and moxifloxacin. Clinicians should be aware that Mycobacterium kyorinense can cause pleuritis without pulmonary involvement. When mycobacterial species are isolated from the pleural fluid, precise identification and drug susceptibility testing are warranted.

Does repeated pleural culture increase the diagnostic yield of Mycobacterium tuberculosis from tuberculous pleural effusion in HIV-negative individuals?

Background

Despite recent advances in methods for culturing Mycobacterium tuberculosis (MTB), the diagnostic yield of tuberculous pleural effusion (TBPE) remains unsatisfactory. However, unlike repeated sputum cultures of pulmonary tuberculosis, little is known about the role of repeated pleural cultures. We examined whether repeated pleural cultures are associated with increased MTB yield from TBPE.

Methods

A multicenter, retrospective cohort study was performed from January 2012 to December 2015 in South Korea. Patients were categorized into two groups: single- or repeated-culture groups. The diagnostic yield of MTB and clinical, radiological, and pleural fluid characteristics were evaluated.

Results

Among the 329 patients with TBPE, 77 (23.4%) had repeated cultures and 252 (76.5%) had a single culture. Pleural culture was performed twice in all 77 patients in the repeated-culture group at a 1-day interval (inter-quartile range, 1.0–2.0). In the repeated-culture group, the yield of MTB from the first culture was 31.2%, which was similar to that in the single-culture group (31.2% vs. 29.8%, P = 0.887). However, the yield of MTB from the second culture (10/77, 13.0%) was more than that from the first. These results may be attributable to the insufficient immune clearance for MTB invasion into the pleural space between the first and second cultures. Over time, the yield of the second cultures decreased from 17.4% to 6.7% and then 6.3%. Finally, the overall yield of MTB in the repeated- and single-culture groups was 44.2% and 29.8% respectively (P < 0.001).

Conclusions

The results showed that repeated pleural cultures increased MTB yield from TBPE in human immunodeficiency virus-negative individuals. Furthermore, repeated cultures may increase yield when carried out for two consecutive days.

Inflammatory markers and clinical characteristics for predicting persistent positivity of interferon gamma release assay in dialysis population

The interferon-gamma release assay (IGRA) is useful for diagnosing latent tuberculosis infection (LTBI), however the rate of negative conversion is high, especially in dialysis patients. Few studies have focused on predicting persistently positive patients who are at high risk of tuberculosis reactivation. We screened dialysis patients, and used QuantiFERON-TB Gold In-tube (QFT-GIT) to identify LTBI. Of the 157 participants who had initially positive QFT-GIT, 82 had persistently positivity and 75 had negative conversion. The persistently positive group were younger, more were current smokers, and had higher plasma level of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and QFT-GIT responses than the negative conversion group. Multivariate logistic regression for persistent positivity revealed that high plasma sTREM-1 and QFT-GIT response, young age and TB contact history were independent factors. Currently smoking had borderline significance. The area under the receiver operating characteristic curve using the multi-factor model was 0.878, higher than 0.821 by QFT-GIT response of 0.95 IU/ml. In conclusion, dialysis patients with persistent LTBI status may be associated with a young age, high plasma sTREM-1, strong QFT-GIT response, currently smoking, and TB contact history. If resources are limited, these five predictors can be used to prioritize QFT-GIT-positive dialysis patients for LTBI treatment.

Revisiting tuberculous pleurisy: pleural fluid characteristics and diagnostic yield of mycobacterial culture in an endemic area

BACKGROUND

Tuberculous pleurisy is traditionally indicated by extreme lymphocytosis in pleural fluid and low yield of effusion culture. However, there is considerable inconsistency among previous study results. In addition, these data should be updated due to early effusion studies and advances in culture methods.

METHODS

From January 2004 to June 2009, patients with tuberculous pleurisy were retrospectively identified from the mycobacteriology laboratories and the pathology and tuberculosis registration databases of two hospitals in Taiwan where tuberculosis is endemic. Pleural fluid characteristics and yields of mycobacterial cultures using liquid media were evaluated.

RESULTS

A total of 382 patients with tuberculous pleurisy were identified. The median lymphocyte percentage of total cells in pleural fluids was 84% (IQR 64-95%) and 17% of cases had a lymphocyte percentage of <50%. The lymphocyte percentage was negatively associated with the probability of a positive effusion culture (OR 0.97; 95% CI 0.96 to 0.99). The diagnostic yields were 63% for effusion culture, 48% for sputum culture, 79% for the combination of effusion and sputum cultures, and 74% for histological examination of pleural biopsy specimens.

CONCLUSION

The degree of lymphocyte predominance in tuberculous pleurisy was lower than was previously thought. The lymphocyte percentage in pleural fluid was negatively associated with the probability of a positive effusion culture. With the implementation of a liquid culture method, the sensitivity of effusion culture was much higher than has been previously reported, and the combination of effusion and sputum cultures provided a good diagnostic yield.

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies

BACKGROUND

Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema.

METHODS

Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression.

RESULTS

One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis.

CONCLUSIONS

Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

Pyo-pneumothorax in patients with active pulmonary tuberculosis: an analysis of 17 cases without intrapleural fibrinolytic treatment

OBJECTIVE

To review the medical records of patients with active pulmonary tuberculosis (TB) and pyo-pneumothorax (PPT).

SUBJECTS AND METHODS

Medical records of 17 patients (14 male, 3 female, mean age 23.8 years, range 20-52) with PPT and active pulmonary tuberculosis at Gulhane Military Medical Academia Haydarpasa Training Hospital, Istanbul, Turkey, were reviewed from January 1998 to December 2002. The patients were treated with chest tube drainage and chemotherapy. Intrapleural fibrinolytic agents or irrigation was not performed.

RESULTS

Pleural fluid samples were available in 14 patients and the mean levels of LDH, protein and glucose in the pleural fluid were 1,767 +/- 944 U/l, 5.2 +/- 1.4 g/dl and 31.7 +/- 22.6 mg/dl, respectively. Mycobacterium tuberculosis was detected in the pleural effusion of 3 patients. The duration of chest tube drainage was longer in cases who underwent open drainage (p = 0.014). At the end of the treatment period 10 patients developed pleural thickening, 4 of them underwent decortication and pneumonectomy was also done in 1 patient. The development of pleural thickening was related to the level of pleural fluid glucose (p = 0.04).

CONCLUSION

This study shows that while taking care of patients with pulmonary TB the physician must be aware of the complication of PPT and that adequate chemotherapy and drainage must be duly performed.