Advertisement

Neutrophilic Loculated Tuberculous Pleural Effusion: Incidence, Characteristics and Differentiation From Complicated Parapneumonic Effusion

      Abstract

      Objectives

      Tuberculous pleural effusion (TPE) is generally characterized by lymphocytic exudative effusion, either free-flowing or loculated. However, patients can also have neutrophilic loculated TPE, although little data are available concerning the incidence and characteristics of this form of TPE. It is important to differentiate between neutrophilic loculated TPE and complicated parapneumonic effusion (PPE), which also shows neutrophilic loculated effusion but needs a different management approach. The present study evaluated the incidence and characteristics of neutrophilic loculated TPE and differentiated it from complicated PPE.

      Materials and Methods

      Between 2009 and 2014, a cohort of patients with TPE was retrospectively reviewed in a South Korean referral hospital. Clinical, laboratory, computed tomography and pleural fluid findings of patients with neutrophilic loculated TPE were compared to those of patients with neutrophilic free-flowing TPE and complicated PPE, respectively.

      Results

      Neutrophilic TPE was observed in 33 (10%) out of 344 patients with TPE. Of these, 10 (30%) patients exhibited loculation of the pleural fluid. These patients showed distinct pleural fluid characteristics. The classical pleural fluid biomarker levels were more intense than those observed in 23 patients with neutrophilic free-flowing TPE, but similar to those of 54 patients with complicated PPE. A high mycobacterial burden was observed in the pleural fluid, and favorable outcomes were achieved with antituberculosis drug administration alone. Nodular parenchymal lesions and pleural fluid adenosine deaminase levels were independent discriminators of neutrophilic loculated TPE and PPE.

      Conclusions

      These results may be helpful to understand and manage patients with neutrophilic loculated TPE and differentiate them from patients with complicated PPE.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of the Medical Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Porcel J.M.
        • Vives M.
        Etiology and pleural fluid characteristics of large and massive effusions.
        Chest. 2003; 124: 978-983
        • Maji A.
        • Maikap M.K.
        • Jash D.
        • et al.
        Role of common investigations in aetiological evaluation of exudative pleural effusions.
        J Clin Diagn Res. 2013; 7: 2223-2226
        • Valdes L.
        • Pose A.
        • San Jose E.
        • et al.
        Tuberculous pleural effusions.
        Eur J Intern Med. 2003; 14: 77-88
        • Porcel J.M.
        Tuberculous pleural effusion.
        Lung. 2009; 187: 263-270
        • Han D.H.
        • Song J.W.
        • Chung H.S.
        • et al.
        Resolution of residual pleural disease according to time course in tuberculous pleurisy during and after the termination of antituberculosis medication.
        Chest. 2005; 128: 3240-3245
        • Cases Viedma E.
        • Lorenzo Dus M.J.
        • Gonzalez-Molina A.
        • et al.
        A study of loculated tuberculous pleural effusions treated with intrapleural urokinase.
        Respir Med. 2006; 100: 2037-2042
        • Valdes L.
        • Alvarez D.
        • San Jose E.
        • et al.
        Tuberculous pleurisy: a study of 254 patients.
        Arch Intern Med. 1998; 158: 2017-2021
        • Lin M.T.
        • Wang J.Y.
        • Yu C.J.
        • et al.
        Mycobacterium tuberculosis and polymorphonuclear pleural effusion: incidence and clinical pointers.
        Respir Med. 2009; 103: 820-826
        • Ruan S.Y.
        • Chuang Y.C.
        • Wang J.Y.
        • et al.
        Revisiting tuberculous pleurisy: pleural fluid characteristics and diagnostic yield of mycobacterial culture in an endemic area.
        Thorax. 2012; 67: 822-827
        • Lee J.
        • Lee S.Y.
        • Lim J.K.
        • et al.
        Radiologic and laboratory differences in patients with tuberculous and parapneumonic pleural effusions showing non-lymphocytic predominance and high adenosine deaminase levels.
        Infection. 2015; 43: 65-71
      1. World Health Organization. Tuberculosis. WHO report. Available at: http://www.who.int./tb; 2012.

        • Bielsa S.
        • Palma R.
        • Pardina M.
        • et al.
        Comparison of polymorphonuclear- and lymphocyte-rich tuberculous pleural effusions.
        Int J Tuberc Lung Dis. 2013; 17: 85-89
        • Kim H.J.
        • Lee H.J.
        • Kwon S.Y.
        • et al.
        The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis.
        Chest. 2006; 129: 1253-1258
        • Porcel J.M.
        • Esquerda A.
        • Bielsa S.
        Diagnostic performance of adenosine deaminase activity in pleural fluid: a single-center experience with over 2100 consecutive patients.
        Eur J Intern Med. 2010; 21: 419-423
        • Lee J.
        • Lee S.Y.
        • Yoo S.S.
        • et al.
        Clinical value of whole-blood interferon-gamma assay in patients with suspected pulmonary tuberculosis and AFB smear- and polymerase chain reaction-negative bronchial aspirates.
        Diagn Microbiol Infect Dis. 2012; 73: 252-256
        • Kwon J.S.
        • Cha S.I.
        • Jeon K.N.
        • et al.
        Factors influencing residual pleural opacity in tuberculous pleural effusion.
        J Korean Med Sci. 2008; 23: 616-620
        • Sahn S.A.
        • Iseman M.D.
        Tuberculous empyema.
        Semin Respir Infect. 1999; 14: 82-87
        • Antony V.B.
        • Repine J.E.
        • Harada R.N.
        • et al.
        Inflammatory responses in experimental tuberculosis pleurisy.
        Acta Cytol. 1983; 27: 355-361
        • Delacour H.
        • Bousquet A.
        • Fontan E.
        • et al.
        Pleural adenosine deaminase determination: an inter-laboratory comparison is required.
        J Infect. 2014; 68: 103
        • Porcel J.M.
        • Vives M.
        • Esquerda A.
        • et al.
        Usefulness of the British Thoracic Society and the American College of Chest Physicians guidelines in predicting pleural drainage of non-purulent parapneumonic effusions.
        Respir Med. 2006; 100: 933-937
        • Ko J.M.
        • Park H.J.
        • Kim C.H.
        Pulmonary changes of pleural tuberculosis: up-to-date CT imaging.
        Chest. 2014; 146: 1604-1611
        • Bhatnagar R.
        • Maskell N.A.
        Treatment of complicated pleural effusions in 2013.
        Clin Chest Med. 2013; 34: 47-62