Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis in Korea. Tuberculous pleurisy presents a diagnostic and therapeutic problem due to the limitations of traditional diagnostic tools. There have been many clinical research works during the past decade. Recent studies have provided new insight into the tuberculous pleurisy, which have a large impact on clinical practice. This review is a general overview of tuberculous pleurisy with a focus on recent findings on the diagnosis and management.
Adenosine Deaminase ; Diagnosis ; Korea ; Pleural Effusion ; Tuberculosis ; Tuberculosis, Pleural*

PURPOSE: To describe radiologic differences between tuberculous pleural effusion and empyema on the basis of computed tomography(CT). MATERIALS AND METHODS: We reviewed retrosepectively CT findings of 50 patients with pathologically and grossly proved empyema. Twenty-two patients had empyema, and 28 patients had tuberculous pleurisy. RESULTS: CT findings known to be useful in differentiating tuberculous pleural effusion from empyema (1) contour and extent of pleural thickening, (2) mediastinal pleural involvement, (3)accumulation of extrapleural tissue and (4) change of ipsilateral thoraic volume of empyema. However, none of the above findings were helpful in the differential diagnosis of empyema. CONCLUSION: The differentation of tubrculous pleurisy from pyogenic empyema may be not possible with CT findings only.
Diagnosis, Differential ; Empyema* ; Humans ; Pleural Effusion* ; Pleurisy ; Tuberculosis, Pleural

We reviewed the computed tomography (CT) of 32 patients with upper lobe collapse to assess the significance of small atypically redistributed pleural effusion (ARPE) in distinguishing the bronchogenic carcinoma (BC) form tuberculosis (TB). Upper lobe collapse was caused by BC in 21 and by TB in 11 of the 32 patients. Small ARPE was Present in 14 of 21 patients with BC and two of the 11 patients with TB, Among 16 patients with small ARPE, CT showd mediastinal invasion in 11 (69%) patients and mediastinal lymphadenopathyn 6 (38%). Our results suggest that small ARPE associated with upper lobe collapse can be used a an auxiliary sign in the differential diagnosis between BC and TB.
Carcinoma, Bronchogenic* ; Diagnosis, Differential ; Humans ; Pleural Effusion* ; Tuberculosis ; Tuberculosis, Pulmonary*

BACKGROUND: Tuberculosis is the most common cause of pleural effusion in Korea. But the differential diagnosis of pleural effusion is important because malignancy and pneumonia are also other common causes of pleural effusion. Adenosine deaminase (ADA) activity is used to differentiate tuberculous pleurisy from non-tuberculous pleural effusion. However, some cases of non-tubercu-lous effusion show increased activity of ADA. Therefore, this study is for evaluating diagnostic efficacy of the ADA isoenzyme activity in the diagnosis of tuberculous pleurisy. METHODS: The activity of total ADA and ADA2 isoenzyme activity and ratio of ADA2/ADA in 293 patients with pleural effusion were measured. Then, it was compared to conventional and PCR-hybridization methods for tuberculous pleurisy. RESULTS: Total ADA and ADA2 isoenzyme activity in tuberculous pleurisy were 81.8+/-29.5 U/L and 67.0+/-23.2, respectively, which were significantly higher than non-tuberculous effusion (20.3+/-21.3 U/L and 12.5+/-9.0 U/L1). With a cut-off level of 45 U/L in total ADA activity and the ratio of ADA2/ADA 0.6 or greater, the sensitivity and specificity for tuberculous pleurisy were 92.1% and CONCLUSIONS: Total ADA and ADA isoenzyme activities are useful to differentiate tuberculous pleurisy from non-tuberculous pleural effusion compared to conventional methods. Especially, various combinations of the total ADA, the ADA2 isoenzyme activities, and the ratio of ADA2/total ADA show high diagnostic efficacy for tuberculous pleurisy.
Adenosine Deaminase* ; Adenosine* ; Diagnosis ; Diagnosis, Differential ; Humans ; Korea ; Pleural Effusion ; Pneumonia ; Sensitivity and Specificity ; Tuberculosis ; Tuberculosis, Pleural*

BACKGROUND: Etiologic diagnosis of pleural effusion is usually made by clinical characteristics, pleural fluid analysis and pleural biopsy. But, despite careful diagnostic study, the cause of pleural effusion cannot be found in about 20 percent of patients, especially in loculated pleural effusions. Tuberculous pleurisy is one of the most common cause of pleural effusion in Korea. But, pleural fluid culture for Mycobacterium tuberculosis are positive in only 20 to 30 percent of patients and typical pleural biopsy finding in less than 50 percent of patients with this disease. In recent studies, adenosine deaminse(ADA) and its isoenzymes were proposed to be a useful diagnostic tool for differential diagnosis of pleural effusion We investigated the pattern of ADA and its isoenzyme activities in various cause of pleural effusions to evaluate the diagnostic value of measuring ADA and its isoenzymes. METHOD: We measured total ADA and its isoenzyme activities in pleural fluid and serum from 54 patients with pleural effusion(25 tuberculous pleural effusion, 10 parapneumonic effusion, 14 malignant pleural effusion, 5 transudative pleural effusion), including 5 loculated tuberculous pleural effusions and 6 loculated parapneumonic effusions. Total ADA activity was measured by the spectrophotometric method and ADA2 isoenzyme activity was measured with same method using EHNA, potent inhibitor of ADA1 isoenzyme activity. RESULT: Total ADA activity of tuberculous pleural effusion was higher than malignant pleural effusion(p<0.01), but no significant difference was found between tuberculous pleural effusion and parapneumonic effusion (tuberculous pleural effusion:148.9+/-9.91U/L, parapneumonic effusion:129.0+/-119.41U/L, malignant pleural effusion 48.7+/-9.71U/L). Percentage of ADA2 activity to total ADA activity(ADA2%) of pleural effusion of tuberculous pleurisy was higher than parapneumonic effusion(p<0.05), but no significant difference was found between tuberculous pleural effusion and malignant pleural effusion(tuberculous pleural effusion: 57.2+/-10.7%, parapneumonic effusion: 35.9+/-17.8%, malignant pleural effusion: 60.7+/-4.1%). In loculated pleural effusion, ADA2% of tuberculous pleural effusion was higher than parapneumoriic effusion(tuberculous pleural effusion: 53.3+/-3.9%, parapneumonic effusion: 27.8+/-7.9%). CONCLUSION: Measurement of ADA isoenzyme activity is useful for differentiating tuberculous pleural effusion from parapneumonic effusion, especially in loculated pleural effusion.
Adenosine* ; Biopsy ; Diagnosis ; Diagnosis, Differential ; Humans ; Isoenzymes ; Korea ; Mycobacterium tuberculosis ; Pleural Effusion* ; Pleural Effusion, Malignant ; Tuberculosis, Pleural

BACKGROUND: For the diagnosis of pleural tuberculosis, polymerase chain reaction (PCR) of pleural effusion specimens has shown very low sensitivity, which might be due to the small number of bacilli in the samples. The purpose of this investigation is to determine whether the sensitivity of PCR testing can be improved when increasing the amount of pleural effusion specimens. METHODS: We prospectively analyzed pleural effusion specimens obtained from 53 patients for whom the exclusion of the possibility of tuberculous pleural effusion was necessary. We performed Mycobacterium tuberculosis PCR testing using the Cobas Amplicor MTB test (Roche Diagnostic Systems) with three different amounts (10ml, 25ml, and 50ml) of pleural effusion specimen in each patient. Pleural tuberculosis was defined as having one of the following: culture-positive pleural fluid sample, histopathologic finding consistent with tuberculosis on pleural biopsy, culture-positive sputum specimen, and/or positive response to anti-tuberculous medication without other possible causes of pleural effusion. RESULTS: Of the 53 patients, 26 received the diagnosis of pleural tuberculosis. The sensitivities of AFB smearing, Mycobacterium tuberculosis culture of pleural effusion specimen, pleural biopsy, and measurement of ADA were 3.8%, 15.4%, 84.6%, and 88.5%, respectively. The results of PCR testing were positive for 3 (11.5%), 4 (15.4%), and 3 (11.5%) of the 26 patients when using 10ml, 25ml, and 50ml of pleural effusion specimens, respectively. These results did not show a statistically significant difference in the sensitivity of PCR testing when increasing the amount of pleural effusion samples (p>0.05, symmetry exact test). CONCLUSION: For specimens such as pleural effusion, in which the bacillary load is very low, the clinical utility of PCR testing seems highly limited with the kits designed for the diagnosis of pulmonary tuberculosis. An increased amount of pleural effusion sample does not improve the sensitivity of PCR testing.
Biopsy ; Diagnosis ; Humans ; Mycobacterium tuberculosis ; Pleural Effusion* ; Polymerase Chain Reaction* ; Prospective Studies ; Sputum ; Tuberculosis ; Tuberculosis, Pleural* ; Tuberculosis, Pulmonary

BACKGROUND: Traditionally, tuberculous pleurisy has been known to largely develop as primary tuberculosis. However, as the incidence of tuberculosis decrease, recent studies have shown reactivation tuberculosis has become the main cause of tuberculous pleurisy. METHODS: 141 cases of tuberculous pleurisy, between January 2003 and February 2006, at the Dankook university hospital. were retrospectively studied. The patients were divided into primary and reactivation tuberculosis. based on the history and radiological characteristics, and the clinical, radiological characteristics at the time of diagnosis and residual pleural thickening after 6 month of chemotherapy were compared between the two groups. RESULTS: 1. Of the 141 tuberculous pleurisy cases, in 135 it was possible to differentiate between primary and reactivation tuberculosis. 2. Of the 135 tuberculous pleurisy cases, 38 (28%) showed a primary tuberculosis pattern, and 98 (72%) showed a reactivation tuberculosis pattern. 3. There were no significant differences between primary and reactivation tuberculosis in relation to age, sex, duration of symptom, amount of pleural effusion, pleural fluid WBC, lymphocyte count, and level of protein, LDH and ADA at the time of diagnosis. 4. 124 patients were followed for 6 months after diagnosis of tuberculous pleurisy, and there was no significant difference in the residual pleural thickening between primary and reactivation tuberculosis. CONCLUSION: In South Korea, a reactivation disease is currently a more common cause of tuberculous pleurisy than a primary disease. There was no difference in the clinical characteristics between primary and reactivation tuberculosis.
Diagnosis ; Drug Therapy ; Humans ; Incidence ; Korea ; Lymphocyte Count ; Pleural Effusion ; Retrospective Studies ; Tuberculosis ; Tuberculosis, Pleural*

BACKGROUND: Diagnosis of tuberculous pleurisy is sometimes difficult using conventional diagnostic methods. We have investigated the utility of pleural fluid cell IFN-gamma production assay in the diagnosis of tuberculous pleurisy. METHODS: We prospectively performed pleural fluid cell IFN-gamma production assay in 39 patients with tuberculous pleural effusions (TPE) and in 26 patients with nontuberculous pleural effusions (NTPE) (13 malignant pleural effusions and 13 parapneumonic effusions). Pleural fluid cells were cultured in DMEM media and stimulated with purified protein derivatives (PPD), and phytohemagglutinin (PHA) for 24 hr. The amount of IFN-gamma released in the culture supernatant was quantitated by IFN-gamma ELISA assay. We have also measured adenosine deaminase (ADA) activities and IFN-gamma concentrations in the pleural fluid. RESULTS: 1) The pleural fluid levels of ADA activity and IFN-gamma concentrations were significantly higher in TPE than NTPE (p<0.01). 2) IFN-gamma production in TPE cells stimulated by PPD (755,266+/-886,636 pg/ml) was significantly higher than NTPE cells (3,509+/-6,980 pg/ml) (p<0.01). By considering the fact that IFN-gamma concentrations over 10,000 pg/ml is a criteria for the diagnosis of TBE, sensitivity and specificity of the test were 97.4 and 92.3%, respectively. 3) The ratios of IFN-gamma production by the stimulation with PPD and PHA (PPD/PHA) were significantly higher in TPE cells (59+/-85) than NTPE cells (5+/-18)(p<0.01). Considering the criteria for the diagnosis of TBE as PPD/PHA ratio over 5, sensitivity and specificity of the test were 76.9 and 92.3%, respectively. CONCLUSION: Pleural fluid cell IFN-gamma production assay may be useful for the diagnosis of tuberculous pleurisy.
Adenosine Deaminase ; Diagnosis* ; Enzyme-Linked Immunosorbent Assay ; Humans ; Pleural Effusion ; Pleural Effusion, Malignant ; Pleurisy ; Prospective Studies ; Tuberculosis ; Tuberculosis, Pleural*

BACKGROUND: Differential diagnosis of lymphocytic pleural effusion is difficult even with many laboratory findings. Nitric oxide(NO) level is higher in the sputum or exhaled breath of patients with active pulmonary tuberculosis than in those without tuberculosis. In addition, there are some reports about the increased level of NO metabolites in body fluids of cancer patients. However, there is no data on the NO levels in the pleural fluid of patients with tuberculous pleurisy. Method : The serum and pleural fluid NO in the patients with acute lymphocytic pleural effusion were analyzed. RESULTS: Of total 27 patients, there were 14 males and average age of patients was 48 years. The final diagnosis was tuberculous pleurisy in 17 cases and malignant pleural effusion in 10. The pleural fluid NO level was 540.1+/-116.4 micrometerol in the tuberculous pleurisy patients and 383.7+/-71.0 micrometerol in the malignant pleural effusion patients. The serum NO level was 624.7+/-142.0 micrometerol in tuberculous pleurisy patients and 394.4+/-90.4 micrometerol in malignant pleural effusion patients. There was no significant difference in the serum and pleural fluid NO level between the two groups. The NO level in the pleural fluid showed a significant correlations with the pleural fluid neutrophil count, the pleural fluid/serum protein ratio, and pleural fluid/serum albumin ratio (p<0.05 in each). The protein concentration, leukocyte and lymphocyte count in the pleural fluid were significantly higher in the tuberculous pleurisy patients than the malignant pleural effusion patients (p<0.05 in each). CONCLUSION: NO is not a suitable marker for a differential diagnosis of lymphocytic pleural effusion. However, the NO level in the pleural fluid might be associated with the neutrophil recruitment and protein leakage in the pleural space.
Body Fluids ; Diagnosis ; Diagnosis, Differential* ; Humans ; Leukocytes ; Lymphocyte Count ; Male ; Neutrophil Infiltration ; Neutrophils ; Nitric Oxide* ; Pleural Effusion* ; Pleural Effusion, Malignant ; Sputum ; Tuberculosis ; Tuberculosis, Pleural ; Tuberculosis, Pulmonary

BACKGROUND: Determining the cause of an exudative pleural effusion is sometimes quite difficult, especially between malignant and tuberculous effusions. Twenty percent of effusions remain undiagnosed even after a complete diagnostic evaluation, including pleural biopsy. The activity of tumor necrosis factor-alpha (TNF-alpha), which is the one of proinflammatory cytokines, is increased in both infectious and malignant effusions. The aim of this study was to investigate the diagnostic efficiency of TNF-alpha activity in distinguishing tuberculous from malignant effusions. METHODS: 46 patients (13 with malignant pleural effusion, 33 with tuberculous pleural effusion) with exudative pleurisy were included. TNF-alpha concentrations were measured in the pleural fluid and serum samples using an enzyme- linked immunosorbent assay (ELISA). In addition, TNF-alpha ratio (pleural fluid TNF-alpha : serum TNF-alpha) was calculated. RESULTS: TNF-alpha concentration and TNF-alpha ratio in the pleural fluid were significantly higher in the tuberculous effusions than in the malignant effusions (p<0.05). However, the serum levels of TNF-alpha in the malignant and tuberculous pleural effusions were similar (p>0.05). The cut off points for the pleural fluid TNF-alpha level and TNF-alpha ratio were found to be 136.4 pg/mL and 6.4, respectively. The sensitivity, specificity and area under the curve were 81%, 80% and 0.82 for the pleural fluid TNF-alpha level (p<0.005) and 76%, 70% and 0.72 for the TNF-alpha ratio (p<0.05). CONCLUSION: We conclude that pleural fluid TNF-alpha level and TNF-alpha ratio can distinguish a malignant pleural effusion from a tuberculous effusion, and can be additional markers in a differential diagnosis of tuberculous and malignant pleural effusion. The level of TNF-alpha in the pleural fluid could be a more efficient marker than the TNF-alpha ratio.
Biopsy ; Cytokines ; Diagnosis, Differential* ; Humans ; Pleural Effusion ; Pleural Effusion, Malignant ; Pleurisy ; Tuberculosis ; Tumor Necrosis Factor-alpha*