Complications and residual pleural thickening after intrapleural instillation of streptokinase with pigtail catheter drainage of tuberculous pleural effusion

Background: Tuberculosis is the most common cause of exudative lymphocytic pleural effusion in India. Residual pleural thickening (RPT) is observed in about 50 percent of patients even after proper treatment with ATT. Pleural fluid drainage either with simple aspiration or with intercostal drainage and addition of corticosteroids along with antitubercular drugs have not shown to influence the incidence of RPT. The present study was undertaken to study the complications and residual effects of tubercular pleural effusion on the patients during the follow up period following intrapleural streptokinase instillation.Methods: Clinical profile, hospital course and outcome of tuberculous pleural effusion patients at the end of six months of anti-tubercular treatment of 50 patients from January 2009 to June 2010 were analyzed. These patients were randomly divided into two groups. One group (n=25) received intrapleural streptokinase via pigtail catheter and the other group (n=25) received intercostal drainage without intrapleural streptokinase instillation. All the patients received standard daily anti TB regimen of 2HERZ/4HR for a total duration of six months. All the patients were followed up for a total duration of 1 year for evidence of any residual pleural thickening.Results: Majority of the patients were above 40 years of age (60%). The male to female ratio was 2.3:1. The major symptoms of the patients were, fever in 44 patients (88%), cough in 42 patients (84%), breathlessness in 33 patients (66%), loss of appetite in 25 patients (50%) and chest pain in 25 patients (50%). Most of the patients had ADA levels between 40-70IU/L (48%) and only 6% had ADA levels below 40IU/L. The incidence of residual pleural thickening in the study group was less as compared to the control group (2.36�49mm vs 9.28�50mm) (p <0.0001).Conclusion: Intrapleural streptokinase instillation with pigtail catheter drainage less number of complications associated with study group and is successful with the decreased incidence of residual pleural thickening during the follow up period.

Serial pulmonary function test abnormality in tuberculous pleural effusion

Background: Pleural effusion is a common clinical problem that frequently causes dyspnoea and poor ventilatory function. In addition to fluid, pleural thickening, septations and calcifications can add to the functional deterioration of lungs. The drainage of pleural effusion is very effective in improving the functionality of lungs. Large volume pleural fluid tapping results in immediate hemodynamic improvement and relief from dyspnoea.Methods: The aim of the present study was to estimate the impact of tubercular pleural effusion on the ventilatory function of the lungs and to find out the correlation between the effect of pleural tapping and functional effect on the lungs. The study comprised of thirty tubercular pleural effusion cases. They were observed for six months by doing serial chest X-rays and pulmonary function test.Results: It was observed that tuberculous pleural effusion causes a restrictive abnormality and small airway obstruction. These abnormalities improve gradually over a period of six months when the patient is on anti-tubercular treatment. The role of any therapeutic intervention towards decreasing these lung function abnormalities will be subject of separate large-scale prospective study.Conclusions: Functional defects and residual pleural thickening has no correlation with the initial severity of pleural effusion.

The Relation of Residual Pleural Thickening with Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases of Pleural Effusion in Patients with Tuberculous Pleuritis / 결핵및호흡기질환

BACKGROUND: Residual pleural thickening (RPT) is the most frequent complication of tuberculous pleurisy (TP), and this can happen despite of administering adequate anti-tuberculous (TB) therapy. Yet there was no definite relation between RPT and other variables. The aim of this study was to examine matrix metalloproteinases (MMPs) and the inhibitors of metalloproteinases (TIMPs) and to identify the factors that can predict the occurrence of RPT. METHODS: The patients with newly-detected pleural effusions were prospectively enrolled in this study from January 2004 to June 2005. The levels of MMP-1, -2, -8 and -9, and TIMP-1 and -2 were determined in the serum and pleural fluid by ELISA. The residual pleural thickness was measured at the completion of treatment and at the point of the final follow-up with the chest X-ray films. RESULTS: The study included 39 patients with pleural fluid (PF). Twenty-three had tuberculous effusion, 7 had parapneumonic effusion, 7 had malignant effusion and 2 had transudates. For the 17 patients who completed the anti-TB treatment among the 23 patients with TP, 7 (41%) had RPT and 10 (59%) did not. The level of PF TIMP-1 in the patients with RPT (41,405.9+/-9,737.3 ng/mL) was significantly higher than that of those patients without RPT (29,134.9+/-8,801.8) at the completion of treatment (p=0.032). In 13 patients who were followed-up until a mean of 8+/-5 months after treatment, 2 (15%) had RPT and 11 (85%) did not. The level of PF TIMP-2 in the patients with RPT (34.4+/-6.5 ng/mL) was lower than that of those patients without RPT (44.4+/-15.5) at the point of the final follow-up (p=0.038). CONCLUSION: The residual pleural thickening in TP might be related to the TIMP-1 and TIMP-2 levels in the pleural fluid.

Factors Associated with Residual Pleural Thickening After Chemotherapy in Tyberculous Pleurisy / 결핵

BACKGROUND: Residual pleural thickening is frequently seen following treatment for tuberculous pleurisy, and pleural decortication is performend occasionally in patients with severe residual pleural thickening. However, predictive factors for the development of residual pleural thickening are uncertain at the initial diagnosis of the tuberculous pleurisy. Therefore, the purpose of this study was to identify the associated factors for residual pleural thickening at initial diagnosis. METHODS: We separated 63 patients diagnosed as tuberculous pleurisy into two groups; group 1 consisted of patients without residual pleural thickening and group 2 comprised patients with residual pleural thickening at the end of tuberculous pleurisy treatment. We analyzed the clinical characteristics, radiological findings, pleural biopsy and characteristics of pleural fluid between group 1 and group 2. RESULTS: The study population and clinical symptoms of the two groups were not significantly different and the duration of symptoms before treatment and the peripheral WBC were similar between the two groups. The presence of pulmonary tuberculosis, pleural fluid loculation or the amount of pleural effusion sid not differ significantly between the thwo groups. The incidence of positive AFB staining(group 1 : 8%, group 2 : 38%) and granuloma(group 1 : 30%, group 2 : 62%) on pleural biopsy specimens was significantly higher in group 2 than in group 1. Pleural fluid WBC and differential count, adenosine deaminase level, pH, preotein level or glucose level did not differ between the two groups. However, group 2 had higher LDH levels (1370±208mg/dl) than group 1 (860±71mg/dl, p<0.05). CONCLUSION: In tuberculous pleurisy, patients with residual pleural thickening following treatment demonstrated a higher incidence of posivive AFB staining and granuloma on the pleural biopsy specimens or higher LDH level in the pleural fluid than patients wihtout residual pleural thickening From these results, we speculate that the amonut of tuberculous bacilli and granuloma are probably correlated with residual pleural thickening in the tuberculous pleurisy.

TNF-alpha, TGF-beta, and fibrinolytic parameters in tuberculous and malignant pleural effusions / 결핵

BACKGROUND: Residual pleural thickening(RPT) develops in about 50% of tuberculous pleurisy(PLTB). Some reports have suggested that elevated TNF-α and impaired fibrinolysis could be the cause of RPT, but until now, the mechanism and predictors of RPT have not been well known. TGF-β has been known to promote fibrogenesis and is increased in tuberculous pleural fluid(PF). PLTB and malignant pleurisy(PLMAL) manifest lymphocyte-dominant exudative pleural effusion, and it has clinical implications in the differentiation of the two diseases, based on the findings of pleural effusion. We performed this study to compare pleural fluid TNF-α, TGF-β, and fibrinolytic parameters between PLTB and PLMAL, and to find the predictors of RPT in PLTB. METHODS: Thirty-five PLTB and 14 PLMAL patients who were admitted to the Asan Medical Center from February 1997 to August 1999 were enrolled. All PLTB patients were prescribed a primary, short-course, anti-tuberculosis regimen. TNF-α, tissue plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), plasminogen, α2-antiplasmin, and D-dimer were measured in both PF and PB, TGF-β was measured only in PF. Clinical characteristics, TNF-α, TGF-β, and fibrinolytic parameters were compared between patients with RPT less than 2 mm and patients with more than 2 mm of the thirty patients who completed the anti-tuberculosis treatment. RESULTS: The levels of TNF-α, tPA, PAI-1, plasminogen, α2-antiplasmin, and D-dimer in PF were higher than those in peripheral blood (PB) in PLTB, whereas only plasminogen, α2-antiplasmin, and D-dimer were higher in PF than in PB in PLMAL. Pleural fluid TNF-α, TGF-β, PAI-1, plasminogen, α2-antiplasmin were increased in PLTB compared with PLMAL, but these factors did not show any further advantages over ADA in differentiation between PLTB and PLMAL. TNF-α, TGF-β, and fibrinolytic parameters did not show any differences between patients with RPT less than 2 mm and patients with RPT more than 2 mm. CONCLUSION: Our data suggest that TNF-α, TGF-β, and fibrinolytic parameters may play some role for the development of RPT in PLTB, but they failed to predict the occurrence of RPT in PLTB. Also these parameters did not seem to have any advantages over ADA in differentiating between two diseases.

Factors Associated with the Development of Pleural Thickening in Tuberculous Pleurisy / 결핵

BACKGROUND: A sizable percentage of tuberculous pleurisy patients are known to have residual pleural thickening(RPT) despite adequate anti-tuberculous chemotherapy. But, the predictive factors related to the development of RPT is not well known. Therefore, we studied to determine which factors are related to the development of RPT after completion of therapy. METHODS: By retrospective review of medical records, fifty-eight patients initially diagnosed as having tuberculous pleurisy between March 1995 and January 1998 were separated into two groups: 27 patients in group 1 had RPT on simple chest radiography, while 31 patients in group 2 had no RPT after 6 month of anti-tuberculous chemotherapy. The clinical characteristics, radiologic findings and pleural fluid findings of the two group were compared at the time of diagnosis and during the course of therapy. RESULTS: 1) 47% of patients had RPT after 6 month of chemotherapy, and RPT was more common in man than in women(54% vs 29%,p=0.092). 2) In group 2 patients, complete resorption of pleural lesion occurred rather late stage of therapy(1-2 month : 26%, 3-4 month :29%, 5-6 month : 45%). 3) Group 1 patients had increased percentage of loculated pleural lesion(26% vs 19%) and increased white blood cell and lymphocyte count, lactate dehydrogenase level in pleural fluid (3527+/-5652 vs 2467+/-2201/ml, 2066+/-2022 vs 1698+/-1835/ml and 1636+/-1143 vs 1441+/-923IU/ml, respectively) than group 2 at the time of diagnosis, but statistically insignificant. 4) Duration of symptom prior to treatment, size of pleural effusion, presence of parenchymal lung lesion, level of total protein, glucose and adenosine deaminase(ADA) activity in pleural fluid were similar in both group. CONCLUSION: 53% of tuberculous pleurisy patients showed slow but complete resorption of pleural lesion after 6 month of chemotherapy. But, no clinical, radiological and pleural fluid findings are predictive for the development of RPT.