From the Guidelines
Tuberculous pleurisy should be treated with a 6-month antituberculous regimen, consisting of isoniazid, rifampin, ethambutol, and pyrazinamide for the initial 2 months, followed by isoniazid and rifampin for an additional 4 months, as recommended by the American Thoracic Society 1. The treatment regimen includes isoniazid (5 mg/kg/day, max 300 mg), rifampin (10 mg/kg/day, max 600 mg), ethambutol (15-25 mg/kg/day), and pyrazinamide (15-30 mg/kg/day) for the initial 2-month intensive phase. Pyridoxine (vitamin B6, 25-50 mg daily) should be added to prevent isoniazid-induced peripheral neuropathy. Some key points to consider in the treatment of tuberculous pleurisy include:
- Therapeutic thoracentesis may be necessary to relieve symptoms of large effusions, but complete drainage is not always required as the fluid typically resolves with appropriate TB treatment 1.
- Corticosteroids, such as prednisone, may be considered in certain cases, as they have been shown to reduce the development of residual pleural thickening and improve symptoms such as fever, chest pain, and dyspnea, although the added benefit on symptoms may be minimal when complete drainage is performed 1.
- Patients should be monitored for medication side effects, including hepatotoxicity, visual disturbances, and peripheral neuropathy.
- Early diagnosis and complete treatment are essential to prevent complications like fibrothorax and chronic pleural thickening. In cases of tuberculous empyema, treatment consists of drainage, often requiring a surgical procedure, and antituberculous chemotherapy, with surgery being undertaken by experienced thoracic surgeons when needed 1.
From the Research
Definition and Incidence of Tuberculous Pleurisy
- Tuberculous pleurisy is a condition associated with small numbers of bacteria, and it occurs in up to 30% of patients with tuberculosis 2, 3.
- The percentage of patients with pleural effusion is comparable in human immunodeficiency virus (HIV)-positive and HIV-negative individuals, although HIV-positive patients with CD4+ counts <200 cells x mL(-1) are less likely to have a tuberculous pleural effusion 2.
Pathogenesis and Immunology
- Tuberculous pleurisy is thought to occur as a result of a delayed hypersensitivity reaction to mycobacterial antigens 3.
- Pleural cells become activated and produce cytokines as a response to mycobacteria, leading to intramacrophage and direct cytotoxic elimination of mycobacteria, granuloma formation, and fibrosis 2, 3.
Diagnosis
- The most useful diagnostic tests for tuberculous pleurisy are the levels of adenosine deaminase and interferon gamma in the pleural fluid 2, 3.
- Elevation of either of these compounds in lymphocytic pleural effusions is virtually diagnostic of tuberculous pleurisy 3.
- Detection of mycobacterial DNA in the pleural fluid by the polymerase chain reaction is an interesting test, but its usefulness in the diagnosis of tuberculous pleurisy needs further confirmation 2, 3.
Treatment
- The recommended treatment for tuberculous pleurisy is a 6-month regimen of isoniazid and rifampicin, with the addition of pyrazinamide in the first 2 months 2, 3.
- A 6-month treatment regimen with isoniazid and rifampicin (6HR) is as effective as treatment regimen of isoniazid, rifampicin, and pyrazinamide (6HR2Z) for pleural-TB, with fewer adverse effects 4.
- HIV patients may require a longer treatment period 2, 3.
- The general use of corticosteroids is not recommended, but they can be used in individuals who are markedly symptomatic 2.