Diagnostic Utility of Sago-Like Nodules on Gross Thoracoscopic Appearance in Tuberculous Pleural Effusion and Their Correlation with Final Histo-Microbiologic Findings
Background: Distinguishing tuberculous pleural effusion (TPE) from other causes of exudative effusion is often challenging. Delay in treatment initiation can occur while awaiting histo-microbiologic confirmation owing to the paucibacillary nature of the disease. Sago-like nodules are the most common visual finding on gross thoracoscopic appearance. The primary objective was to determine the diagnostic utility of the presence of sago-like nodules on gross thoracoscopic appearance in TPE to help justify early initiation of tuberculosis (TB) treatment based on their finding while awaiting final histo-microbiologic confirmation. Secondary objective was to study the correlation between the presence of sago-like nodules and the final histo-microbiologic findings in pleural biopsy specimens. Methods: This was a retrospective-descriptive study of all patients with exudative pleural effusion who underwent diagnostic medical thoracoscopy (MT) at Hamad General Hospital during an eight-year period (from January, 2008 to December, 2015). Results: The presence of sago-like nodules on gross thoracoscopic appearance of the pleural surface had a sensitivity of 58%, a specificity of 89% and a positive predictive value of 97% for TPE with a diagnostic accuracy of 62%. There is significant association between the presence of sago-like nodules and demonstration of granulomatous inflammation in pleural biopsy specimens (P = 0.000). There is no association between sago-like nodules and positive TB smear and culture in biopsy specimens. Conclusion: The presence of sago-like nodules on gross thoracoscopic appearance has a high specificity and positive predictive value for TPE and significantly correlates with the presence of granulomatous inflammation. Patients from TB prevalent areas with exudative pleural effusion and sago-like nodules on gross thoracoscopic appearance may be commenced on TB chemotherapy while awaiting final histologic confirmation.
References
[1]
(2017) Global Tuberculosis Report 2017. World Health Organization, Geneva.
http://apps.who.int/iris/bitstream/handle/10665/259366/9789241565516-eng.pdf?sequence=1
[2]
Zhai, K., Lu, Y. and Shi, H.-Z. (2016) Tuberculous Pleural Effusion. Journal of Thoracic Disease, 8, E486-E494. https://doi.org/10.21037/jtd.2016.05.87
[3]
Ibrahim, W.H., Ghadban, W., Khinji, A., Yasin, R., Soub, H., Al-Khal, A.L. and Bener, A. (2005) Does Pleural Tuberculosis Disease Pattern Differ among Developed and Developing Countries? Respiratory Medicine, 99, 1038-1045.
https://doi.org/10.1016/j.rmed.2004.12.012
[4]
Vorster, M.J., Allwood, B.W., Diacon, A.H. and Koegelenberg, C.F. (2015) Tuberculous Pleural Effusions: Advances and Controversies. Journal of Thoracic Disease, 7, 981-991.
[5]
Hooper, C., Gary Lee, Y.C. and Maskell, N., On Behalf of the BTS Pleural Guideline Group (2010) Investigation of a Unilateral Pleural Effusion in Adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65, ii4eii17.
[6]
Diacon, A.H., Van de Wal, B.W., Wyser, C., Smedema, J.P., Bezuidenhout, J., Bolliger, C.T., et al. (2003) Diagnostic Tools in Tuberculous Pleurisy: A Direct Comparative Study. European Respiratory Journal, 22, 589-591.
https://doi.org/10.1183/09031936.03.00017103a
[7]
Kong, X.L., Zeng, H.H., Chen, Y., Liu, T.T., Shi, Z.H., Zheng, D.Y., et al. (2014) The Visual Diagnosis of Tuberculous Pleuritis under Medical Thoracoscopy: A Retrospective Series of 91 Cases. European Review for Medical and Pharmacological Sciences, 18, 1487-1495.
[8]
Thomas, M., Ibrahim, W.H., Raza, T., Mushtaq, K., Arshad, A., Ahmed, M., et al. (2017) Medical Thoracoscopy for Exudative Pleural Effusion: An Eight-Year Experience from a Country with a Young Population. BMC Pulmonary Medicine, 17, 151.
[9]
Liu, J.Y., Xiong, L., Zhang, M., Shuai, S.Y., Wei, X.S., Ye, L.L., et al. (2017) Medical Thoracoscopy in China—The Present Status and the Future. Journal of Thoracic Disease, 9, 406-413. https://doi.org/10.21037/jtd.2017.02.39
[10]
Lee, P. and Colt, H.G. (2013) Pleuroscopy in 2013. Clinics in Chest Medicine, 34, 81-91. https://doi.org/10.1016/j.ccm.2012.11.003
[11]
Hong, K.D., Lee, S.I. and Moon, H.Y. (2011) Comparison between Laparoscopy and Noninvasive Tests for the Diagnosis of Tuberculous Peritonitis. World Journal of Surgery, 35, 2369-2375. https://doi.org/10.1007/s00268-011-1224-2
[12]
Bhargava, D.K., Shriniwas, C.P., Nijhawan, S., Dasarathy, S. and Kushwaha, A.K. (1992) Peritoneal Tuberculosis: Laparoscopic Patterns and Its Diagnostic Accuracy. The American Journal of Gastroenterology, 87, 109-112.
[13]
Casalini, A.G., Mori, P.A., Majori, M., Anghinolfi, M., Silini, E.M., Gnetti, L., et al. (2018) Pleural Tuberculosis: Medical Thoracoscopy Greatly Increases the Diagnostic Accuracy. ERJ Open Research, 4, pii: 00046-2017.
[14]
Wang, Z., Xu, L.L., Wu, Y.B., Wang, X.J., Yang, Y., Zhang, J., et al. (2015) Diagnostic Value and Safety of Medical Thoracoscopy in Tuberculous Pleural Effusion. Respiratory Medicine, 109, 1188-1192. https://doi.org/10.1016/j.rmed.2015.06.008
[15]
Guirado, E. and Schlesinger, L.S. (2013) Modeling the Mycobacterium tuberculosis Granuloma—The Critical Battlefield in Host Immunity and Disease. Frontiers in Immunology, 4, 98. https://doi.org/10.3389/fimmu.2013.00098
[16]
Valdés, L., Alvarez, D., San José, E., Penela, P., Valle, J.M., García-Pazos, J.M., et al. (1998) Tuberculous Pleurisy: A Study of 254 Patients. JAMA Internal Medicine, 158, 2017-2021.
[17]
Khattab, M.A., Khan, F.Y., Al Maslamani, M., Al-Khal, A.L., El Gendy, A., Al Soub, H., et al. (2015) Pulmonary and Extra Pulmonary Tuberculosis in Qatar: A First Retrospective Population-Based Study. Advances in Infectious Diseases, 5, 148-153.
https://doi.org/10.4236/aid.2015.54018
