Tuberculous Pleural Effusion

CASE

A 7 year-old girl presents to a hospital in Lilongwe, Malawi with worsening tactile fevers, shortness of breath, and productive cough over the past week. Her mother reports subjective weight loss, but denies night sweats, hemoptysis, or a significant respiratory history.

The patient’s vital signs were significant for a temperature of 100.6 F, pulse of 69, blood pressure of 107/72, tachypnea to 33, and hypoxia to 87% on room air. Her physical exam was notable for diminished breath sounds throughout the right side. An x-ray was performed revealing a large right-sided pleural effusion (Figure 1). A bedside ultrasound was then performed, showing a loculated pleural effusion (Figure 2). The patient underwent a therapeutic and diagnostic thoracentesis, returning straw colored fluid. In addition to standard pleural fluid studies, the patient’s fluid was also sent for Xpert MTB/RIF nucleic acid amplification test given the high prevalence of tuberculosis in the region, eventually returning a confirmatory diagnosis of Mycobacterium tuberculosis

Figure 1. Chest x-ray of a 7 year-old girl presenting with worsening shortness of breath, productive cough, and subjective fevers, found to have a large right-sided pleural effusion.

Figure 1. Chest x-ray of a 7 year-old girl presenting with worsening shortness of breath, productive cough, and subjective fevers, found to have a large right-sided pleural effusion.

Figure 2. Still image of a point-of-care ultrasound performed on a 7 year-old girl with a large right-sided pleural effusion, showing a loculated pleural effusion.

Figure 2. Still image of a point-of-care ultrasound performed on a 7 year-old girl with a large right-sided pleural effusion, showing a loculated pleural effusion.

 FINAL DIAGNOSIS

Tuberculous pleural effusion

 

CLINICAL PRESENTATION

The classic chest x-ray findings of primary pulmonary tuberculosis (TB) are parenchymal consolidation with or without hilar lymphadenopathy. Tuberculous pleural effusion (also known as tuberculous pleurisy) is the second most common form of extrapulmonary TB (after lymphatic involvement) (Figure 3), and is the most common cause of pleural effusions in TB endemic regions.[1] In children, tuberculous pleural effusion most often occur in the setting of primary TB,[2] whereas in adults they occur most frequently due to reactivation disease.[3] Patients typically present with an acute febrile illness with nonproductive cough and pleuritic chest pain, though dyspnea, night sweats, and weight loss can also occur. Most tuberculous pleural effusions are unilateral and, in contrast to our patient, small to moderate in size.[4] On chest x-ray, pleural disease is often appreciated.[5] Loculation of pleural effusions is not uncommon in tuberculous pleural effusion, and is thought to be due to direct pleural infection and the resulting intense intra-pleural inflammation and organization.[6]

Figure 3. Common sites of extrapulmonary TB.

Figure 3. Common sites of extrapulmonary TB.

 

DIAGNOSIS

 Tuberculous pleural effusion should be suspected in patients with pleural effusion and TB risk factors including history of TB infection, TB exposure, or time spent in TB endemic regions. Unfortunately, definitive diagnosis of tuberculous pleural effusion can be challenging. Tuberculin skin test and interferon-gamma release assays do not distinguish between latent tuberculosis infection and active tuberculosis disease, and thus cannot be used for definitive diagnosis. The gold standard of diagnosis remains demonstration of M. tuberculosis in pleural fluid or pleural biopsy specimen.[4] Presumptive diagnosis can reasonably be made in patients with a known history of pulmonary TB and a pleural effusion without any alternative cause.

In the undifferentiated patient, a workup for pulmonary TB should be initiated including sputum smear and culture for acid-fast bacilli (AFB). Next, a diagnostic thoracentesis can be performed. Pleural fluid from tuberculous pleural effusion is typically an exudative, lymphocyte-predominant pleural effusion, and should be sent for smear and culture for AFB, though cultures are positive in less than 30% of HIV-uninfected patients,[4] and only approximately 50% of HIV-infected patients with CD4 counts less than 100 cells/mm3 (a higher sensitivity due to the greater bacterial burden).[7] Pleural fluid should also be sent for analysis, with typical findings shown in Table 1. 

Laboratory test Typical finding
Color Straw colored(14)
Protein concentration >3.0 g/dL(15)
LDH >500 international units/L(15)
pH <7.4
Glucose 60-100 mg/dL(15)
ADA >40 units/L
Cell count 1,000-6,000 cells/mm^3.(16)
Early neutrophil predominance. After the
first few days, lymphocytes predominate.(15)
Table 1. Pleural fluid findings typical for tuberculous pleural effusion.

 A presumptive diagnosis can be made if there is a lymphocytic-to-neutrophil ratio >0.75 and ADA >40 units/L.[8-10] While nucleic acid amplification (NAA) tests for M. tuberculosis that are FDA-approved for use with sputum have not yet been approved for pleural fluid in the United States, some laboratories use NAA testing of pleural fluid as a validated, "off-label" application. If the patient still remains undifferentiated after this testing and there is concern for the medically complex patient or suspected drug resistance, a pleural biopsy can be pursued by thoracoscopy or closed percutaneous needle biopsy with resulting tissue sample sent for AFB smear and culture as well as histopathology for evaluation of granulomas. Additionally, all patients with suspected tuberculous pleural effusions should be tested for HIV infection.

 

TREATMENT

The mainstay of treatment of tuberculous pleural effusion is antituberculosis therapy, the same as active pulmonary tuberculosis. A typical drug regimen consists of isoniazid, rifampin, pyrazinamide, and ethambutol for 8 weeks, followed by isoniazid and rifampin for an additional 18 weeks. Empiric antituberculous therapy is warranted if a presumptive diagnosis is made as described above, and patients typically defervesce within two weeks and pleural fluid is resorbed within six weeks. However, some patients take up to two months to defervesce with fluid resorption taking up to four months. In areas with high rates of antituberculous drug resistance, organism isolation is more critical as it can guide drug selection. Currently, corticosteroids are not recommended as an adjuvant therapy as there is insufficient evidence for benefit.[11] Therapeutic thoracentesis can be considered in patients with larger pleural effusions or significant dyspnea, as it has been shown to more quickly resolve dyspnea, though there is no effect on long-term outcomes.[12,13]

 

DISPOSITION AND CASE CONCLUSION

Empiric antituberculosis therapy was initiated after thoracentesis, with resulting clinical improvement.  The patient was soon thereafter discharged to complete the remainder of her antituberculosis therapy through a directly observed therapy (DOT) program and was doing well at her follow up visit.

 

TEACHING POINTS

  • Tuberculosis is the most common cause of pleural effusions in endemic regions.

  • The gold standard of diagnosis is demonstration of M. tuberculosis in pleural fluid or pleural biopsy specimen.

  • A presumptive diagnosis can be made if pleural fluid shows a lymphocytic-to-neutrophil ratio >0.75 and ADA >40 units/L.

  • Treatment of tuberculous pleural effusions is the same as for pulmonary tuberculosis.


Faculty Reviewer: Dr. Lauren Allister

 


REFERENCES

  1.  Zhai, K, Lu, Y, Shi, HZ. Tuberculous pleural effusion. J Thorac Dis 2016;8:E486-94.

  2. Merino, JM, Carpintero, I, Alvarez, T, Rodrigo, J, Sanchez, J, Coello, JM. Tuberculous pleural effusion in children. Chest 1999;115:26-30.

  3. Torgersen, J, Dorman, SE, Baruch, N, Hooper, N, Cronin, W. Molecular epidemiology of pleural and other extrapulmonary tuberculosis: a Maryland state review. Clin Infect Dis 2006;42:1375-82.

  4. Gopi, A, Madhavan, SM, Sharma, SK, Sahn, SA. Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest 2007;131:880-9.

  5. Seibert, AF, Haynes, J, Jr., Middleton, R, Bass, JB, Jr. Tuberculous pleural effusion. Twenty-year experience. Chest 1991;99:883-6.

  6. Ko, Y, Kim, C, Chang, B, Lee, SY, Park, SY, Mo, EK, et al. Loculated Tuberculous Pleural Effusion: Easily Identifiable and Clinically Useful Predictor of Positive Mycobacterial Culture from Pleural Fluid. Tuberc Respir Dis (Seoul) 2017;80:35-44.

  7. Gil, V, Cordero, PJ, Greses, JV, Soler, JJ. Pleural tuberculosis in HIV-infected patients. Chest 1995;107:1775-6.

  8. Light, RW. Update on tuberculous pleural effusion. Respirology 2010;15:451-8.

  9. Sahn, SA, Huggins, JT, San Jose, ME, Alvarez-Dobano, JM, Valdes, L. Can tuberculous pleural effusions be diagnosed by pleural fluid analysis alone? Int J Tuberc Lung Dis 2013;17:787-93.

  10. Jimenez Castro, D, Diaz Nuevo, G, Perez-Rodriguez, E, Light, RW. Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J 2003;21:220-4.

  11. Ryan, H, Yoo, J, Darsini, P. Corticosteroids for tuberculous pleurisy. Cochrane Database Syst Rev 2017;3:CD001876.

  12. Bhuniya, S, Arunabha, DC, Choudhury, S, Saha, I, Roy, TS, Saha, M. Role of therapeutic thoracentesis in tuberculous pleural effusion. Ann Thorac Med 2012;7:215-9.

  13. Lai, YF, Chao, TY, Wang, YH, Lin, AS. Pigtail drainage in the treatment of tuberculous pleural effusions: a randomised study. Thorax 2003;58:149-51.

  14. Levine, H, Metzger, W, Lacera, D, Kay, L. Diagnosis of tuberculous pleurisy by culture of pleural biopsy specimen. Arch Intern Med 1970;126:269-71.

  15. Epstein, DM, Kline, LR, Albelda, SM, Miller, WT. Tuberculous pleural effusions. Chest 1987;91:106-9.

  16. Valdes, L, Alvarez, D, San Jose, E, Penela, P, Valle, JM, Garcia-Pazos, JM, et al. Tuberculous pleurisy: a study of 254 patients. Arch Intern Med 1998;158:2017-21.

Money Minutes for Doctors #16 - Purchasing a home, How to Decide & What to Know

LOCATION, LOCATION, LOCATION…that’s it, right?? Turns out ~ not quite!!

This month’s edition of MMFD takes a hard look into the ins and outs of one of the largest purchases a person or family ever have to make…buying a home. It is not as easy as you may think and a measure of research goes a very long way. Back to help us navigate the shifting tides of the real estate market and the shoals of home purchasing is Ms. Katherine Vessenes.

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

QUICK SUMMARY:

Real Estate:

  1. If you have never lived in the area before recommend you rent for the first year because it allows to learn the area and your desired neighborhood preferences

  2. Renting also allows you a chance to recover your finances and build savings

  3. If needed to change that first job can do so easily and not tied to fixed real estate asset

In general do NOT buy a house during residency or fellowship.  Typically at year 15 of a mortgage start to be at 50/50 point where interest and mortgage are equal and start to build true equity.   Thankfully most training programs are not that long.   

In a bad real estate market town house or condo are more difficult to sell vs single home

“Throwing away” money on rental payments is old thinking and need to accept that it costs money to live and rent/mortgage is a necessity

Historically the price of real estate increases c/w inflation.  There are certainly pockets where returns exceed expectations but this is not the norm

Major problem w doctors is buying too much house too soon

How much house can I afford?  2-3 x your annual income assuming no (educational) debt. i.e. if your income was $200,000 you could afford home of $400 – 600,000.  You must run a budget prior to purchasing to know what kind of payment you could handle

Owning a home has many associated costs and fees, below are just a few:

  • Association feeds ($300-500 and much higher depending on location)

  • Maintenance and repairs

  • Furniture and decorating

  • Home owner’s insurance

  • Household help – cleaning, lawn care, snow removal

  • Utilities – electricity, gas, garbage removal

  • Property taxes (tax rates are public and published for each township)

Most people will need to purchase a starter home and don’t think you should get “the house of your dreams” as your very first home

If you live in a state w no income tax then often real estate taxes are higher

If you have or are planning to have a family be sure to consider schools and educational goals of your children.  Most doctors cannot afford private education and thus public education should be a factor in your decision.

AEM Early Access 29: Do Financial Incentives Change Length of Stay Performance in Emergency Departments?

Welcome to the twenty-ninth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON TITLE FOR FULL TEXT, OPEN ACCESS THROUGH August 31):

Do financial incentives change length-of-stay performance in emergency departments? A retrospective study of the Pay-for-Performance program in Metro Vancouver. Yuren Wang, MS, Yichuan Ding, PhD, Eric Park, PhD, Garth Hunte, MD, PhD

LISTEN NOW: AUTHOR INTERVIEW WITH Yichuan Ding, PhD and Eric Park, PhD

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Yichuan Ding, PhD

Assistant Professor, Desautels Faculty of Management, McGill University

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Eric Park, PhD

Assistant Professor, Innovation and Information Management, Faculty of Business and Economics, The University of Hong Kong

ABSTRACT:

Background: Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program.

Methods: We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate—the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit—than patients discharged just after the target.

Results: Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.

Conclusions: The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program—it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.