The tuberculous pleural effusion.

Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease. Educational aims: To demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.

Patients' experience of accessing support for tics from primary care in the UK: an online mixed-methods survey.

BACKGROUND: Tics are common in children and young people and may persist into adulthood. Tics can cause challenges with social, occupational, physical, and academic functioning. The current study explores the perceptions of adults with tics and parents/carers of young people with tics regarding their experience of accessing support from professionals in primary care in the UK. METHODS: Two online cross-sectional surveys were completed by 33 adults with tics and 94 parents/carers of children with tics. Participants were recruited across three online tic support groups. Tic specialist psychologists, academic researchers, and people with lived experience of tics provided feedback on the surveys before they were made available online. Mixed-method analyses were conducted on the surveys. Qualitative data from the free-text responses were analysed using thematic analysis and triangulated with quantitative findings where appropriate. RESULTS: While some participants felt supported by general practitioners (GPs), many felt dismissed. The impact of tics was not always explored, nor information on tics provided, during the consultation. Although 78.7% of participants were referred to secondary care for their tics, some struggled to get the referral. Within secondary care, most adult respondents were assessed by neurologists whilst young people were typically assessed by paediatricians or psychiatrists. Most of these secondary care clinicians did not specialise in tic disorders, with only 27.9% of participants being assessed by tic specialists. Mode waitlist time was 3-6 months for young people and longer for adult respondents. Some participants were referred to multiple secondary care services, spanning neurology, paediatrics, and psychiatry, with each stating that they do not provide support for tics. 21% of participants mentioned being discharged from secondary care with no ongoing support. Almost one-third of respondents accessed support within private healthcare. CONCLUSIONS: Generally, more negative than positive experiences were reported. Possible contributing factors included a lack of clear tic referral pathways, long waitlists, a lack of information about tics provided in primary care appointments and a lack of support offered following diagnosis by secondary care services, together with poor access to tic specialist clinicians. This study highlights areas where improvements to UK services for tics can be made.

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma associated with coeliac disease.

Pulmonary mucosa-associated lymphoid tissue (pMALT) lymphomas are rare, representing <1% of lung malignancies. An association between pMALT and autoimmune conditions has been described, but there is a paucity of documented cases linked to coeliac disease. We present the case of a patient with a history of coeliac disease who presented with weight loss but no respiratory symptoms. CT revealed diffuse endobronchial opacities with associated bronchial dilation and pulmonary nodules. Bronchoscopy confirmed widespread polypoid endobronchial lesions. Histology demonstrated diffuse lymphoid infiltrate which stained positive for CD20. Clonality studies confirmed low grade B cell MALT lymphoma. She was treated with anti CD20 monoclonal antibody, rituximab. Prognosis of pMALT is good with 5-year survival >80%. Thus, an index of suspicion and early detection are vital. This case highlights that pMALT should be considered in patients with non-specific symptoms and coeliac disease. Bronchoscopy is a valuable diagnostic tool to be used in these cases.

Relapse of idiopathic acute fibrinous and organising pneumonia 12 years after successful treatment with corticosteroids.

Acute fibrinous and organising pneumonia (AFOP) is a rare form of interstitial lung disease. It is a pathological diagnosis sharing similarities to organising pneumonia, diffuse alveolar damage and eosinophilic pneumonia, however, is histologically distinct, characterised by intra-alveolar fibrin deposition ('fibrin balls') and associated organising pneumonia. AFOP was first described in 2002, only 150 cases have been reported since. While it has been described in association with infection, autoimmune disorders, connective tissue diseases, drugs, environmental exposures and organ transplant, it can also be idiopathic in nature. AFOP follows an acute course with potential rapid fulminant respiratory failure, or a subacute trajectory with a more favourable prognosis. Corticosteroids are commonly prescribed to induce remission. While cases of relapse of AFOP during weaning or cessation of steroids have been described, there are no published cases of remote relapse of AFOP. We describe a case of idiopathic AFOP, which recurred after 12 years of good health.

Diagnostic accuracy of a clinical prediction rule (CPR) for identifying patients with recent-onset undifferentiated arthritis who are at a high risk of developing rheumatoid arthritis: a systematic review and meta-analysis.

OBJECTIVES: The Leiden clinical prediction rule (CPR) was developed in 2007 to predict disease progression in patients with recent-onset undifferentiated arthritis (UA). This systematic review and meta-analysis investigates the predictive ability of the rule at identifying patients who are at a high risk of developing rheumatoid arthritis (RA). METHODS: A systematic review of the literature search was conducted from 2007 to May 2013 to identify studies that validated the rule. This study adhered to the PRISMA guidelines. The methodological quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity values for each of the cut points were generated using a bivariate random-effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. Bayes' theorem was used to calculate post-test probability of progression from UA to RA. RESULTS: The search identified four relevant studies, resulting in six data sets (n = 1084). A cut point of ≥ 9 was identified as the optimal cut point for determining progression to RA. It is associated with a greater pooled specificity (0.99, 95% CI 0.95-1.00) than sensitivity (0.31, 95% CI 0.24-0.37). Using Bayes' theorem, a score of ≥ 9 points increased the pre-test probability from 40.04% to 93.63%. A less stringent cut-off of ≥ 8 also identified a significant proportion of patients at risk of RA who have a high likelihood of progressing to RA (LR + 9.5, 95% CI 6.21-14.54). CONCLUSION: A cut point of ≥ 9 offers an optimal estimate for identifying patients with UA who are at a high risk of developing RA and warrant intervention. However, a number of methodological limitations identified across studies suggest that the results should be interpreted cautiously and that further validation of the Leiden CPR is necessary.