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

Muhammad Umar, Zafar Iqbal, Anila Basit, Mohammad Yousaf Khan, Arshad Javaid


Background: Pleural tuberculosis is one of the commonest causes of pleural
effusion in regions endemic for tuberculosis including Pakistan.
Objective: To study the types of clinico-radiological presentations of pleural
tuberculosis and analyze misuse of antibiotics prior to its diagnosis.

Methodology: Prospective analysis of clinico-radiological features and
misuse of antibiotics among 58 patients with pleural tuberculosis, over 24
months (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 21
females (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 sided
pleural effusion, 38 (48.3%) with right pleurisy & 2 (3.4%) had bilateral pleural
effusions. 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 on
ultrasound chest examination. Diagnosis of pleural TB was made on the basis
of either positive pleural biopsy (caseating granulomatous inflammation) with
lymphocytic (51.72%) or neutrophilic (5.17%) exudative effusions or exudative
lymphocytic effusion alone (43.10%). Duration of illness prior to hospital visit
was ≤ 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 high
grade continuous or intermittent pyrexia while 24 (41.4%) had low grade
continuous fever with 24 (41.4%) subjects experiencing night sweats. Forty
(69%) patients had cough and 13 (22.4%) had mild sputum production. Forty
three (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 the
least frequent symptoms in 9 (15.5%) and 2 (3.4%) individuals respectively.
Forty nine (84.5%) patients had visited physicians prior to presenting to the
hospital and misuse of antibiotics was reported by 42 (72.4%) patients.
Association of age with duration of illness prior to hospital visit showed
statistical significance as majority (56.2%) of patients having ≤ 30 years of age
had ≤ 2 weeks duration of illness compared to only 3 patients in 31-50 years of
age group and 3 subjects having ages > 50 years (p-value = 0.048). Association
of 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) and
antibiotics misuse (p-value = 0.026) also revealed significant associations.

Conclusion: Tuberculous pleural effusions appear moderate to large on chest
radiographs, and presents in an acute manner, and should be investigated
earlier to avoid diagnostic delay and prevent misuse of antibiotics.


Tuberculous pleural effusion; malignant pleural effusion; exudates; pleural biopsy; pleural fluid protein

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