Pleurisy tuberculosis A15.6, A16.5

s. a. Pleuritis and tuberculosis

A pleuritis tuberculosa is an acute inflammation of the mesothelium of the parietal pleura and possibly also of the visceral pleura, which can affect only individual sections or the entire pleura. It can occur on one or both sides.

Pleuritis is divided into one with exudate formation and one without exudate formation:

• Pleuritis sicca (dry pleuritis or also called fibrinous pleuritis)
• Pleuritis exsudativa (here there is an effusion in the pleural space between the pleural leaves)

In most cases of pleuritis, the sicca pleuritis develops into an exudative pleuritis. In the case of tuberculosis pleuritis, however, it is not uncommon for the primary cause to be exudative pleuritis.

In many parts of the world, infection with Mycobacterium tuberculosis is the most common cause of pleural effusion. However, in Central and Western Europe as well as in the USA, tuberculous pleuritis is now rarely found.

Pleuritis tuberculosa is - after lymph node tuberculosis - with about 20% the second most frequent manifestation of extrapulmonary tuberculosis.

Pleuritis tuberculosa can develop in the course of an infection with Mycobacterium tuberculosis. It is considered a hyperergic reaction to the tuberculous protein in the pleural cavity.

It occurs:

1. closely related to primary tuberculosis of the lung
2. as post-primary pleuritis due to direct perforation of a subpleural focus
3. from a focal point close to the pleura per continuitatem
4. rarely also haematogenic, then also possible as a bilateral disease
5. as accompanying pleuritis

Frequently, the primary cause of tuberculous pleuritis is exudative pleuritis with pleural effusion. However, pleuritis sicca can also occur initially, which then changes into an exudative form.

The patients complain - in addition to the symptoms of the underlying disease - about:

• Respiratory, inspiratory and expiratory thoracic pain; with the development of an effusion, this pain recedes or is no longer present
• Dyspnoea (especially after the occurrence of effusion)
• in case of pleuritis exsudativa, patients prefer to lie on the diseased side

Sonography: Initially there is a discrete, irregular thickening of the pleural leaves. The pleural reflex band is irregular (so-called pleural roughening). However, the pleura can be displaced depending on breathing.

In the further course - or also initially - a narrow, wall-standing effusion between the pleural leaves often occurs and often a small basal angular effusion is found on the affected side of the thorax. In this case - in contrast to the X-ray image - even small effusions (from 20 ml) can be shown.

X-rays: The localisation and extent of the effusion can be assessed on the X-ray. However, only effusions of about 100 ml or more can be shown (when the image is taken lying down and with the lateral beam). In the case of a p.a. image taken in a standing position, only effusions of approx. 200 ml or more can be displayed.

The adenosine deaminase (ADA) should be determined in pleural effusion, as its sensitivity is about 95% and specificity about 90%. The ADA shows values of more than 40 IU/l with a positive result. At very low values, tuberculosis can practically be excluded.

Lysozyme is also detectable in a tuberculous etiology of the effusion.

A further tuberculosis marker is the increased interferon gamma with > 140 pg / ml and a positive PCR.

Auscultation

• Pleurisy sicca is characterized by fibrinous deposits, which cause the typical crunching in- and expiratory rubbing sound, which is also called "snowball crunching".
• as soon as an exudate is formed, the respiratory sound is attenuated or eliminated
• above the effusion there is often compression breathing(bronchial breathing within a strip-shaped zone)

Percussion

• initially inconspicuous as long as pleuritis sicca exists
• Attenuation as soon as effusion formation occurs (pleuritis exsudativa)

Vocal fremitus

• initially inconspicuous (pleuritis sicca)
• attenuated to absent as soon as effusion formation occurs in the context of pleuritis exsudativa

Pleural punctate

• The punctate appears amber-colored, sometimes hemorrhagic, and contains a high percentage of lymphocytes (in many cases > 85 %) ). In the early stages, neutrophilic granulocytes may predominate; later, more lymphocytes are found.
• Glucose shows normal values or is decreased.
• The protein content is more than 50% of the serum protein concentration.
• The pH is 7.3, sometimes < 7.2.
• Thus, it is an exudate.
• In concomitant pleurisy in the context of post-primary tuberculosis, no pathogens are usually detectable in the exudate. In only 20% of cases can the pathogen be detected culturally.

Thoracoscopy

• Only thoracoscopy can provide histological confirmation in more than 90% of cases by detecting granulomatous epithelioid cell changes in the pleura. Cultural detection also has a very high hit rate.

Sometimes the diagnosis can only be made after several attempts. In persistent cases, atypical mycobacteria should also be considered.

• Pleural effusion of other genesis
• in case of high values of adenosine deaminase, rheumatoid arthritis, malignancy, empyema or parapneumonic effusion are also possible differential diagnoses.

If a tuberculous effusion is detected, there is an indication for antituberculosis therapy, regardless of whether an infiltrate is found in the X-ray image or not.

The previously held opinion that such an effusion is always self-limiting in the absence of an infiltrate has proven to be incorrect. In the meantime, it has been proven that CT scans of such cases usually reveal small foci in the lung parenchyma or lymph nodes.

In order to prevent the formation of rind, an initial pleural drainage is recommended, if this has not already been carried out during thoracoscopy.

The drug treatment of pleuritis corresponds to the treatment of pulmonary tuberculosis.

With parallel administration of glucocorticoids, the duration of the fever and the breath-dependent pain can be shortened. However, the benefit has not been proven with certainty.

The treatment of tuberculous pleuritis is always carried out with a combination of drugs. There are 4 main substances available as first-choice agents: isoniazid, rifampicin, pyrazinamide and ethambutol. Recently, according to the WHO, the second-choice agent is streptomycin, as it cannot be administered orally and is no longer used in several countries for the treatment of uncomplicated tuberculosis.

The following dosage is recommended for daily administration:

• Isoniazid (INH) 5 mg/kg KW, max. 300 mg
• Rifampicin (RMP) 10 mg/kg KW, max 600 mg
• Pyrazinamide (PZA) 25 mg/kg KW, max 2500 mg
• Ethambutol (EMB)15 mg/kg KW, max. 1600 mg

A standard short therapy for adults is a 6-month chemotherapy. In the first 2 months, the so-called initial phase, a combination of INH, RMP, PZA and EMB is treated.

In the following 4-month stabilization phase, treatment is continued with a combination of INH and RMP.

The drugs should be administered orally 1 x / d as a single dose. .

In some countries, intermittent drug administration with 3 x weekly intake is practised during the stabilisation phase. This procedure is not recommended in Germany, as the maximum therapeutic safety is only given if the drugs are taken daily.

If there are any doubts about the regular intake of the drugs, the intake must be constantly monitored.

The success of the therapy should be checked regularly once a month, including the organs that are at risk from taking the medication. These include:

• Liver function with INH, RMP, PZA (additive effect!)
• ophthalmological controls in case of EMB
• Renal function with aminoglycosides
• Check audiogram for aminoglycosides
• Blood glucose monitoring with additional administration of cortisone (see above)

The patient's body weight should also be checked regularly.

Negative cultures are to be expected in more than 80% of patients after 2 months of combination therapy.

For tuberculous pleuritis, I have no information from the literature on the prognosis. Therefore, it can be assumed that the prognosis corresponds most closely to that of pulmonary tuberculosis.

For this applies:

With early and appropriate treatment, tuberculosis is curable. However, the decisive factor is primarily the good compliance of the patient. Multiple resistances and additional severe concomitant diseases as well as a higher age worsen the prognosis.

Notifiable evidence of pathogens in accordance with the Infection Protection Act (IfSG) § 6 and § 7:

According to the IfSG § 6 there is a medical obligation to report to the public health department responsible for the patient both in case of illness and death from tuberculosis requiring treatment, even without bacteriological evidence already being available.

In addition, persons who have fallen ill with tuberculosis requiring treatment and those who discontinue or refuse treatment must be reported to the health office.

According to § 7 of the IfSG, the investigating laboratory must report the direct detection of mycobacterium tuberculosis / africanum and mycobacterium bovis. The same applies to the detection of acid-resistant rods in sputum and the result of the resistance determination.

The notification to the public health department must be made by name and at the latest 24 hours after the knowledge has been obtained. In addition, information on the country of birth, year of entry into Germany and nationality must be provided.