From the Guidelines
Pleural tuberculosis should be treated with a 6-month regimen of antituberculous chemotherapy, consisting of isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampin for an additional 4 months, as recommended by the American Thoracic Society/ Centers for Disease Control and Prevention/Infectious Diseases Society of America 1. The treatment of pleural tuberculosis involves the use of standard antituberculous chemotherapy, with the goal of curing the infection and preventing long-term complications.
- The standard four-drug regimen for tuberculosis is recommended, which 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, max 2 g) for 2 months, followed by isoniazid and rifampin for an additional 4 months, totaling 6 months of therapy.
- Diagnosis requires thoracentesis with pleural fluid analysis showing lymphocyte-predominant exudate with elevated adenosine deaminase levels, and pleural biopsy may be necessary if fluid analysis is inconclusive.
- Therapeutic thoracentesis can relieve symptoms but isn't always required as the effusion typically resolves with anti-tuberculosis therapy.
- Corticosteroids are generally not recommended unless there's significant respiratory compromise, as they do not reduce the development of residual pleural thickening, but may provide symptomatic relief in some cases 1.
- Patients should be monitored for medication side effects including hepatotoxicity, optic neuritis (with ethambutol), and peripheral neuropathy (with isoniazid, which can be prevented with pyridoxine supplementation).
- In cases of tuberculous empyema, treatment consists of drainage (often requiring a surgical procedure) and antituberculous chemotherapy, with the optimum duration of treatment not established 1.
From the Research
Pleural Tuberculosis Treatment
- The treatment of pleural tuberculosis (TB) has been studied in several research papers, with a focus on the efficacy of different treatment regimens 2, 3.
- A study published in 2019 compared the long-term efficacy of a 6-month treatment regimen with isoniazid and rifampicin (6HR) with a treatment regimen of isoniazid, rifampicin, and pyrazinamide (6HR2Z) for pleural-TB, and found that 6HR is as effective as 6HR2Z treatment for pleural-TB, with fewer adverse effects 2.
- Another study published in 1994 found that tuberculous pleurisy responds well to a two-drug regimen of antituberculous therapy given for six months, with no treatment failures observed 3.
Drug Resistance in Pleural Tuberculosis
- Drug resistance is a concern in the treatment of pleural TB, with approximately 10% and 6-10% of pleural Mycobacterium tuberculosis isolates resistant to at least one first-line anti-TB drug or at least isoniazid, respectively 4.
- The prevalence of multidrug-resistant-pleural and extensively drug-resistant-pleural TB is 1-3% and 0-1%, respectively 4.
- In suspected drug-resistant TPE, every effort is warranted to isolate M. tuberculosis to perform drug susceptibility testing and provide guided therapy 4.
Treatment Regimens for Pleural Tuberculosis
- The standard treatment for active tuberculosis (TB) is a first-line therapy that includes isoniazid, rifampin, pyrazinamide, and ethambutol for the initial two-month phase, followed by isoniazid and rifampin for 4 to 7 months 5.
- However, for pleural TB, a 6-month treatment regimen with isoniazid and rifampicin (6HR) has been shown to be effective, with fewer adverse effects compared to a treatment regimen that includes pyrazinamide (6HR2Z) 2.
- Supervised six-months treatment of newly diagnosed pulmonary tuberculosis using isoniazid, rifampin, and pyrazinamide with and without streptomycin has also been studied, with no significant difference in relapse rates between the two regimens 6.