The efficacy and safety of adjunctive corticosteroids in the treatment of tuberculous pleurisy: a systematic review and meta-analysis

Expert Review on Contemporary Management of Common Benign Pleural Effusions

Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.

Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022

Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE.

The Diagnostic Value of Medical Thoracoscopy Pleural Biopsy, Ultrasound-guided Pleural Biopsy, and Closed Pleural Biopsy in Tuberculous Pleurisy: A propensity score matching analysis.. [DOI: 10.21203/rs.3.rs-2099835/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and objective For diagnosis of exudative pleural effusion in tuberculous pleurisy, medical thoracoscopic pleural biopsy (MTPB) enables direct vision and is most widely applied, although ultrasound-guided pleural biopsy (USPB) and closed pleural biopsy (CPB) are also viable. This retrospective study compared the diagnostic efficiencies and safety of USPB, CPB, and MTPB. Methods Patients enrolled from 2014 through 2020 underwent USPB, CPB, or MTPB (n = 69, 69, and 110, respectively). Propensity score matching (PSM) analysis was used to compare the diagnostic sensitivities of CPB, MTPB, and USPB. The secondary outcomes were postoperative complications and hospitalization stay. Results PSM analysis resulted in 40 (USPB vs. CPB), 47 (USPB vs. MTPB), and 52 (CPB vs. MTPB) matched pairs. The diagnostic sensitivities of the USPB and CPB groups were 72.5% and 55.0% (P = 0.162); that of USPB and MTPB were 70.2% and 80.9% (P = 0.337); the CPB and MTPB groups were comparable(P = 0.152). The rates of associated pain and subcutaneous emphysema of the MTPB group were higher than that of the USPB or CPB (P = 0.000, both).Hospitalization time of the MTPB group was longest, and significantly longer than that of the USPB (P = 0.029). Conclusions While the three techniques were similarly effective in diagnosing tuberculous pleurisy, USPB and CPB showed fewer associated complications and shorter hospital stays compared with MTPB. The image guidance offered by USPB benefited reduction in postoperative complications.

Cytokine storm in tuberculosis and IL-6 involvement

Tuberculosis is probably the most seasoned illness of the humanity. Intricacies or subsequent death emerging from these infections are frequently connected with cytokine storm. Interleukin-6 (IL-6) plays a crucial role in the immune response to tuberculosis. Therefore, there is a need to research some new therapeutic approaches to block IL-6 signaling that are right now being applied to the M. tuberculosis. In this review, we investigate the implication of IL-6 in the context of tuberculosis research.

Diagnostic value of combined pleural interleukin-33, adenosine deaminase and peripheral blood tuberculosis T cell spot detection TB for tuberculous pleurisy

Background

To investigate the correlation between pleural fluid interleukin-33 (IL-33) and adenosine deaminase (ADA) and peripheral blood tuberculosis T cell spot detection (T-SPOT.TB), and the combined value of the three tests for the diagnosis of tuberculous pleurisy.

Methods

79 patients with pleural effusion admitted from June 2017 to December 2018 were enrolled. They were divided into tuberculous pleural effusion (TPE) group (57 cases, 72.2%) and malignant pleural effusion group (17 cases, 21.5%), pneumonia-like pleural effusion group (5 cases, 6.3%). Correlation between pleural fluid IL-33, pleural effusion ADA and peripheral blood T-SPOT.TB was analyzed, comparison of the three separate and combined diagnostic efficacy was also performed.

Results

The levels of IL-33, ADA and peripheral blood T-SPOT.TB in patients with TPE were significantly higher than those in non-TPE (P < 0.001). The level of pleural fluid IL-33 was positively correlated with pleural effusion ADA and peripheral blood T-SPOT.TB. The Area under the ROC curve (AUC) of TPE diagnosed by pleural IL-33, ADA and peripheral blood T-SPOT.TB were 0.753, 0.912 and 0.865, respectively. AUC for combined detection of pleural effusion IL-33, ADA and peripheral blood T-SPOT.TB is the largest, with a value of 0.962. Specificity is 100% and sensitivity is 88.5%.

Conclusion

Combined detection of pleural effusion IL-33, ADA and peripheral blood T-SPOT.TB can improve the diagnostic efficacy of tuberculous pleurisy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06575-w.

Tuberculosis: An Update on Pathophysiology, Molecular Mechanisms of Drug Resistance, Newer Anti-TB Drugs, Treatment Regimens and Host- Directed Therapies

Human tuberculosis (TB) is primarily caused by Mycobacterium tuberculosis (Mtb) that inhabits inside and amidst immune cells of the host with adapted physiology to regulate interdependent cellular functions with intact pathogenic potential. The complexity of this disease is attributed to various factors such as the reactivation of latent TB form after prolonged persistence, disease progression specifically in immunocompromised patients, advent of multi- and extensivelydrug resistant (MDR and XDR) Mtb strains, adverse effects of tailor-made regimens, and drug-drug interactions among anti-TB drugs and anti-HIV therapies. Thus, there is a compelling demand for newer anti-TB drugs or regimens to overcome these obstacles. Considerable multifaceted transformations in the current TB methodologies and molecular interventions underpinning hostpathogen interactions and drug resistance mechanisms may assist to overcome the emerging drug resistance. Evidently, recent scientific and clinical advances have revolutionised the diagnosis, prevention, and treatment of all forms of the disease. This review sheds light on the current understanding of the pathogenesis of TB disease, molecular mechanisms of drug-resistance, progress on the development of novel or repurposed anti-TB drugs and regimens, host-directed therapies, with particular emphasis on underlying knowledge gaps and prospective for futuristic TB control programs.

Therapeutic host-directed strategies to improve outcome in tuberculosis

Bacille Calmette-Guérin (BCG) is the only licenced tuberculosis (TB) vaccine, but has limited efficacy against pulmonary TB disease development and modest protection against extrapulmonary TB. Preventative antibiotic treatment for Mycobacterium tuberculosis (Mtb) infections in high-prevalence settings is unfeasible due to unclear treatment durability, drug toxicity, logistical constraints related to directly observed treatment strategy (DOTS) and the lengthy treatment protocols. Together, these factors promote non-adherence, contributing to relapse and establishment of drug-resistant Mtb strains. Although antibiotic treatment of drug-susceptible Mtb is generally effective, drug-resistant TB has a treatment efficacy below 50% and can, in a proportion, develop into progressive, untreatable disease. Other immune compromising co-infections and/or co-morbidities require more complex prevention/treatment approaches, posing huge financial burdens to national health services. Novel TB treatment strategies, such as host-directed therapeutics, are required to complement pathogen-targeted approaches. Pre-clinical studies have highlighted promising candidates that enhance endogenous pathways and/or limit destructive host responses. This review discusses promising pre-clinical candidates and forerunning compounds at advanced stages of clinical investigation in TB host-directed therapeutic (HDT) efficacy trials. Such approaches are rationalized to improve outcome in TB and shorten treatment strategies.

Central Venous Catheter Based Closed Thoracic Drainage in the Treatment of Tuberculous Pleuritis

Objective:

To explore the clinical effect of central venous catheter closed thoracic drainage in the treatment of tuberculous pleurisy.

Methods:

One hundred and four patients with tuberculous pleurisy who were admitted to Binzhou People’s Hospital from August 2016 to August 2017 were divided into a control group and a treatment group according to random number table method, 52 each. The control group was treated with conventional pleural puncture and drainage, while the treatment group was treated with closed central venous catheter based thoracic drainage. The clinical efficacy, improvement time of clinical symptoms, total volume of drainage, pleural thickness, and improvement of quality of life and occurrence of adverse reactions were compared between the two groups.

Results:

Pleural effusion, fever and chest tightness of the treatment group disappeared earlier (P<0.05); the hospitalization time in the treatment group was less than that in the control group (P<0.05); the total amount of drainage in the treatment group was lower than that in the control group (P<0.05); the pleural thickness of the treatment group was higher than that in the control group (P<0.05); the quality of life score in the treatment group was significantly higher than that in the control group (P<0.05). The total effective rates of the treatment group and the control group were 93.5% and 85%, respectively, with a significant difference (P<0.05). The incidence of adverse reactions in the treatment group was significantly lower than that in the control group, with a significant difference (P<0.05).

Conclusion:

Central venous catheter based closed thoracic drainage is more effective than conventional thoracic puncture and drainage in the treatment of tuberculous pleurisy. It can accelerate the improvement of clinical symptoms, improve the quality of life of patients, and reduce the incidence of complications. It is worth popularizing and applying.

Tuberculous pleural effusion: diagnosis & management

Background: Tuberculosis (TB) is the world's leading cause of death from infectious disease. The World Health Organization (WHO) recognized 6.3 million new TB cases in 2017, 16% corresponding to extrapulmonary forms; pleural tuberculosis (PT) is the most common extrapulmonary form in adults. PT diagnosis is often challenging because the scarcity of bacilli in pleural fluid (PF), sometimes requiring invasive procedures to obtain pleural tissue for histological, microbiological or molecular examination. In regions of medium and high disease prevalence, adenosine deaminase (ADA), interferon gamma (IFN-γ) and interleukin 27 (IL-27) dosages are useful to establish presumptive diagnosis in patients with compatible clinical/radiological picture who present with lymphocytic pleural effusion. PT treatment is similar to the pulmonary TB treatment regimen recommended by WHO. Area covered: In this update, we present a PT review, including epidemiology, pathogenesis, clinical features, diagnosis, and therapy. Expert opinion: There is no PF test alone accurate for PT diagnosis, despite the evolution in clinical laboratory. ADA, IFN-γ and IL-27 are valuable laboratory biomarkers; however, IFN-γ and IL-27 are quite expensive. Molecular tests present low sensitivity in PF, being useful for diagnostic confirmation. Multidrug therapy remains the PT treatment choice. Advancing research in immunotherapy may bring benefits to PT patients.

Ultrasound-Guided versus Thoracoscopic Pleural Biopsy for Diagnosing Tuberculous Pleurisy Following Inconclusive Thoracentesis: A Randomized, Controlled Trial

BACKGROUND Traditional diagnostic methods for tuberculosis (TB) cannot be reliably applied to tuberculous pleurisy. Therefore, this prospective, randomized, controlled trial was performed to compare the diagnostic sensitivity and safety of ultrasound-guided cutting-needle pleural biopsy versus thoracoscopic pleural biopsy in patients suspected of tuberculous pleurisy following inconclusive thoracentesis. MATERIAL AND METHODS A total of 196 adult patients with acid-fast bacillus (AFB)-negative exudative pleural effusions clinically suspected of tuberculous pleurisy were recruited. Enrollees were randomized into 2 cohorts: ultrasound-guided cutting-needle pleural biopsy (n=96) or thoracoscopic pleural biopsy (n=96). The overall diagnostic yields, diagnostic sensitivities for tuberculous pleurisy, and post-procedural complications for both cohorts were statistically compared. RESULTS Ultrasound-guided pleural biopsy displayed an overall diagnostic yield of 83%, while thorascopic pleural biopsy displayed a similar overall diagnostic yield of 86% (χ²=1.88, df=1, p=0.17). There were 127 patients conclusively diagnosed with tuberculous pleurisy, resulting in a tuberculous pleurisy prevalence of 65% in this patient population (66% in the ultrasound cohort vs. 63% in the thoracoscopy cohort; p>0.05). Ultrasound-guided pleural biopsy displayed a sensitivity of 82% in detecting tuberculous pleurisy, while thorascopic pleural biopsy displayed a similar sensitivity of 90% (χ²=1.05, df=1, p=0.30). The sensitivities of these 2 modalities did not significantly differ based on the degree of pleural thickening (p>0.05). Post-procedural complications were minor. CONCLUSIONS Ultrasound-guided and thoracoscopic pleural biopsy both display strong (>80%) but statistically similar overall diagnostic yields for diagnosing pleural effusions following inconclusive thoracentesis. Both modalities also display strong (>80%) but statistically similar sensitivities in detecting tuberculous pleurisy.