Validity of pleural fluid protein in differentiating tuberculous from malignant pleural effusion

Abstract

Background: Pleural tuberculosis is one of the commonest causes of pleuraleffusion in regions endemic for tuberculosis including Pakistan.Objective: To study the types of clinico-radiological presentations of pleuraltuberculosis and analyze misuse of antibiotics prior to its diagnosis.Methodology: Prospective analysis of clinico-radiological features andmisuse of antibiotics among 58 patients with pleural tuberculosis, over 24months (May 2015 to May 2017), presenting at the department of pulmonology,Shaikh Zayed Hospital, FPGMI Lahore, Pakistan.Results: The study included 58 patients including 37 males (64%) and 21females (36%), having ages in the range of 14 to 72 years. Thirty three (56.9%)were indoor and 25 (43.1%) were OPD patients; 38 (48.3%) had left sidedpleural effusion, 38 (48.3%) with right pleurisy & 2 (3.4%) had bilateral pleuraleffusions. Small sized pleural effusions on chest radiographs were seen in 6(10.34%), moderate effusions in 22 (37.93%), larger effusions in 25 (43.10%)and massive effusions in 5 (8.62%) patients with 50% having septations onultrasound chest examination. Diagnosis of pleural TB was made on the basisof either positive pleural biopsy (caseating granulomatous inflammation) withlymphocytic (51.72%) or neutrophilic (5.17%) exudative effusions or exudativelymphocytic effusion alone (43.10%). Duration of illness prior to hospital visitwas ≤ 2 weeks in 24 (41.4%), 2-3 weeks in 14 (24.1%) and ≥ 4 weeks in 20(34.5%) patients. Majority (63.2%) of the patients had intermediate to highgrade continuous or intermittent pyrexia while 24 (41.4%) had low gradecontinuous fever with 24 (41.4%) subjects experiencing night sweats. Forty(69%) patients had cough and 13 (22.4%) had mild sputum production. Fortythree (74.1%) patients also had dyspnea. Chest pain was present in 32 (55%)and 25 (43.1%) had pain of pleuritic nature. Wheeze and hemoptysis were theleast frequent symptoms in 9 (15.5%) and 2 (3.4%) individuals respectively.Forty nine (84.5%) patients had visited physicians prior to presenting to thehospital and misuse of antibiotics was reported by 42 (72.4%) patients.Association of age with duration of illness prior to hospital visit showedstatistical significance as majority (56.2%) of patients having ≤ 30 years of agehad ≤ 2 weeks duration of illness compared to only 3 patients in 31-50 years ofage group and 3 subjects having ages > 50 years (p-value = 0.048). Associationof young age ≤ 30 years with other parameters including fever grade (p-value =0.004), wheeze (p-value=0.050), physicians' visits (p-value = 0.075) andantibiotics misuse (p-value = 0.026) also revealed significant associations.Conclusion: Tuberculous pleural effusions appear moderate to large on chestradiographs, and presents in an acute manner, and should be investigatedearlier to avoid diagnostic delay and prevent misuse of antibiotics.