Images in Interventional Pulmonology
Mycobacterium tuberculosis (MTb) infection is a common global disease. In the United States, nearly 10,000 new cases are diagnosed each year.1 Tuberculous pleuritis is present in only 3% to 5% of patients and accounts for 18% to 20% of extrapulmonary disease.2,3 Medical thoracoscopy is increasingly used to obtain pleural biopsies in the diagnosis of pleural effusions, but is infrequently used in tuberculosis, as the diagnosis can usually be made clinically and with less invasive means, including closed-needle pleural biopsy. The commonly described appearance includes parietal pleura erythema, numerous small yellow-white tubercles, and adhesions.4 Our case highlights a patient with MTb pleuritis presenting with atypically large pleural nodules.
A 70-year-old man with a history of heavy tobacco use initially presented to an outside hospital in Mexico with 1 week of productive cough and white sputum. Chest imaging revealed a large right-sided pleural effusion but pleural fluid analysis was nondiagnostic. His symptoms recurred 4 months later with interval development of bilateral pleural effusions. Pleural fluid analysis from bilateral thoracentesis was again nondiagnostic. The patient subsequently presented to our facility 2 months later, which was 6 months after the initial onset of symptoms. He noted interval worsening of his dyspnea and 8-pound unintentional weight loss.
Physical examination was notable for decreased bilateral breath sounds on auscultation of the chest with dullness to percussion in the lower lung fields. Large bilateral pleural effusions with associated compressive atelectasis were seen on chest imaging (Fig. 1). Serial sputa samples were negative for acid-fast bacilli. Bilateral thoracentesis revealed lymphocyte-predominant exudates with unrevealing cytology and negative for acid-fast bacilli.
Medical thoracoscopic examination of the right thoracic cavity was performed revealing a diffuse macronodular process involving the visceral, parietal, and diaphragmatic surfaces favoring the posterior aspects of the thoracic cavity (Fig. A). Large white nodules were seen along with multiple areas of thickened, erythematous plaques, also favoring the posterior aspects of the pleural space (Fig. A). Thoracoscopic biopsy of the parietal pleural demonstrated non-necrotizing granulomatous pleuritis and acid-fast bacillus (Fig. 2). The patient was treated with rifampin, isoniazid, pyrazinamide, and ethambutol with eventual resolution of pleural disease. Pleural biopsy cultures were positive for pan-sensitive MTb after 23 days.
Pleural effusions are the second most common extrapulmonary disease manifestation of tuberculosis. However, only 18% involve more than two thirds of the pleural space and 1.6% are bilateral.5 Although tuberculous pleuritis can resolve spontaneously, the majority of untreated individuals will go on to develop some form of active disease in the future.6,7 Therefore, it is important to obtain a definitive diagnosis in these patients, particularly when pleural fluid studies are inconclusive.
Although pleural fluid is invariably a lymphocyte-predominant and protein-rich (>5 g/dL) exudate, this finding is nonspecific and most series report positive cultures for MTb in only 20% to 30% of cases.3 In populations with high prevalence of tuberculosis, both closed-needle biopsy and medical thoracoscopy are highly sensitive diagnostic methods.8 Given the greater cost and invasiveness of thoracoscopy, closed-needle biopsy is sufficient in many institutions with limited medical resources. The primary advantage of thoracoscopic over closed-needle pleural biopsy is the ability to obtain visually directed biopsies, thereby increasing diagnostic sensitivity for alternative diagnoses such as malignancy. Adhesiolysis and other pleural interventions, such as talc pleurodesis, may also be performed concurrently when neoplasm is certain.
The primary unique feature highlighted by this case is the presence of large pleural nodules on thoracoscopic examination. Tuberculous pleuritis has a spectrum of visual appearances, although pleural nodules are usually small.4 Sugiyama et al9 described this range of visual appearances with 4 categories of findings: erythematous pleura with white nodules, extensive erythema and edema of the parietal pleura with diffuse and coalescent miliary white nodules, pleural deposition of white fibrin plaques, and progression of deposits to a fibrous stage. The extreme degree of inflammation and size of the nodules seen in this case may relate to the chronic nature of this pleural effusion of >6 months duration.
The visual appearance of this patient’s pleural space is presented to underline that tuberculosis may have an atypical appearance, including large nodules more commonly associated with other etiologies such as neoplasms. In the Western world, tuberculous pleuritis is rarely visualized, as thoracoscopy is seldom necessary for diagnosis. Nevertheless, this appearance of severe inflammation has been described in the past and deserves to be noted.10,11 In summary, thoracoscopic diagnosis depends on biopsy and culture, as common diseases may present with atypical visual appearances.
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Keywords:© 2014 by Lippincott Williams & Wilkins.
medical thoracoscopy; pleuroscopy; pleural biopsy; tuberculosis; tuberculous pleuritis; chronic pleural effusion; bilateral pleural exudates