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      Tuberculous Pleurisy Diagnosed From Massive Pleural Effusion in an Older Patient With No History of Tuberculosis

      case-report
      Author(s): 1 , 2 , 3 , 4 , 2 ,
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: frailty, massive pleural effusion, tuberculous pleurisy, rural hospital, general medicine

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          Abstract

          Tuberculous pleurisy is an infectious disease with a poor prognosis needing early diagnosis. The use of appropriate antituberculosis drugs can improve prognosis. However, the diagnosis of tuberculous pleurisy is often challenging in older patients. Decreased activities of daily living (ADLs) may lead to difficulty in performing invasive procedures to make a definite diagnosis of pleural effusion. We report our experience with a 90-year-old female with the chief complaint of dyspnea with massive pleural effusion. We could not perform an intensive investigation for tuberculous pleurisy. Based on the high value of adenosine deaminase (ADA), we tentatively diagnosed tuberculous pleurisy for the large pleural effusion and treated her well with the initiation of four antituberculosis drugs. ADA in pleural effusion is considered effective for diagnosis among dependent older patients. Furthermore, although it is difficult to diagnose tuberculous pleurisy in older patients, starting treatment to sustain older patients’ lives in their homes is crucial.

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          Update on tuberculous pleural effusion.

          Richard Light (2010)
          The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of gamma-interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.
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            Family Physicians as System-Specific Specialists in Japan’s Aging Society

            Ryuichi Ohta, Chiaki Sano (2022)
            Family medicine is a vital medical specialty in an aging society. The scope of each family doctor’s training and practice varies according to the context of their work, their roles, the organization and resources of the health systems in each country, and their ability to adapt to the healthcare needs of their country. As societal requirements change, so does the role of family medicine. In Japan, family physicians’ educational systems were officially established in 2017 as the nineteenth specialty, following discussions among family physicians, general internal medicine physicians, and hospitalists. Family physicians’ specialization in systems could facilitate access to appropriate health resources with proper timing while respecting the culture and context of each patient. Therefore, family physicians can be systems specialists on the same basis as organ and other specialists. Family physicians include people and families in their ecological systems. Family physicians should therefore specialize in healthcare systems.
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              Etiology and pleural fluid characteristics of large and massive effusions.

              José Manuel Porcel, Manuel Vives (2003)
              To report the etiology of large and massive pleural effusions, and to compare their biochemical fluid characteristics with those of smaller size, and between malignant and nonmalignant conditions. Retrospective chart review of all patients undergoing thoracentesis at an academic medical center in Lleida, Spain, during a 10-year period. Posteroanterior chest radiographs were available in 766 patients during the study period. Large pleural effusions (ie, two thirds or more of the hemithorax without its complete obliteration) were identified in 70 patients (9%), and massive pleural effusions (ie, hemithorax was completely opacified) were identified in 93 patients (12%). A similar etiologic spectrum between large and massive pleural effusions was observed. The most frequent cause of these pleural effusions was malignancy (89 patients; 55%), followed by complicated parapneumonic or empyema (36 patients; 22%), and tuberculosis (19 patients; 12%). Compared with nonmalignant pleural effusions, patients with large or massive malignant pleural effusions were more likely to have pleural fluids with higher RBC counts (18.0 x 10(9) cells/L vs 2.7 x 10(9) cells/L, respectively; p < 0.001) and lower adenosine deaminase (ADA) activity (11.5 vs 31.5 U/L, respectively; p < 0.001), which were the two parameters that were selected by a stepwise logistic-regression model as independent predictors of malignancy. In addition, large/massive malignant pleural effusions showed higher median RBC counts (18.0 x 10(9) cells/L vs 4.3 x 10(9) cells/L, respectively; p < 0.001), higher lactate dehydrogenase levels (641 vs 409 U/L, respectively; p = 0.001), lower pH (7.39 vs 7.42, respectively; p = 0.006) content, but similar cytologic yield (63% vs 53%, respectively; p = 0.171) than smaller malignant pleural effusions. The presence of a large or massive pleural effusion enables the clinician to narrow the differential diagnosis of pleurisy, since most effusions are secondary to malignancy or infections (either bacterial or mycobacterial). Bloody pleural fluid with low ADA content favors a malignant condition.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 8 December 2022
                Publication date (Electronic, collection): December 2022
                Volume: 14
                Issue: 12
                Electronic Location Identifier: e32333
                Affiliations
                [1 ] Family Medicine, Shimane University Faculty of Medicine, Izumo, JPN
                [2 ] Community Care, Unnan City Hospital, Unnan, JPN
                [3 ] Internal Medicine, Shimane University, Izumo, JPN
                [4 ] Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
                Author notes
                Article
                DOI: 10.7759/cureus.32333
                PMC ID: 9828074
                PubMed ID: 36632275
                SO-VID: 2dd4a5aa-9f68-4d12-b9b6-c8829593963f
                Copyright © Copyright © 2022, Nanyoshi et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date accepted : 8 December 2022
                Categories
                Subject: Emergency Medicine
                Subject: Family/General Practice
                Subject: Internal Medicine

                Keywords: frailty,massive pleural effusion,tuberculous pleurisy,rural hospital,general medicine
                Data availability:
                Keywords: frailty, massive pleural effusion, tuberculous pleurisy, rural hospital, general medicine

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