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In high-burden settings, the diagnosis of pleural tuberculosis (TB) is frequently inferred in patients who present with lymphocyte predominant exudative effusions and high adenosine deaminase (ADA) levels. Two recent small retrospective studies suggested that the lactate dehydrogenase (LDH)/ADA ratio is significantly lower in TB than in non-TB pleural effusions and that the LDH/ADA ratio may be useful in differentiating pleural TB from other pleural exudates. We compared the pleural LDH/ADA ratios, ADA levels, and lymphocyte predominance of a prospectively collected cohort of patients with proven pleural TB (n = 160) to those with a definitive alternative diagnosis (n = 68). The mean pleural fluid LDH/ADA ratio was lower in patients with pleural TB than alternative diagnoses (6.2 vs. 34.3, p < 0.001). The area under the receiver operating characteristic curve was 0.92 (p < 0.001) for LDH/ADA ratio and 0.88 (p < 0.001) for an ADA ≥40 U/L alone. A ratio of ≤12.5 had the best overall diagnostic efficiency, while a ratio of ≤10 had a specificity of 90% and a positive predictive value of 95%, with a sensitivity of 78%, making it a clinically useful "rule in" value for pleural TB in high incidence settings. When comparing the LDH/ADA ratio to an ADA level ≥40 U/L in the presence of a lymphocyte predominant effusion, the latter performed better. When lymphocyte values are unavailable, our data suggest that the LDH/ADA ratio is valuable in distinguishing TB effusions from other pleural exudates. [ABSTRACT FROM AUTHOR]

Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti‐tuberculous therapy or a guideline‐based individualized regimen in the case of drug resistance. There is low‐quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short‐ and long‐term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered. [ABSTRACT FROM AUTHOR]

An editorial is presented on common cause of pleural disease in the developed world, followed by metastatic pleural malignancy. Topics include malignant pleural effusion (MPE) being associated with a poor prognosis in most cases and aggravating the performance status; and proportion of patients may require repeated interventions at variable time intervals depending on the underlying aetiology.

The authors convey their thoughts about indwelling pleural catheters (IPCs) for malignant pleural effusions. Topics mentioned include the practice of offering pleural interventions to patients who are truly asymptomatic, the impact of IPCs on the need for further pleural interventions and the number of days spent in hospital, and the use of a low-cost alternative to the current commercially available IPCs.

The article offers information no a study related to the effects of transthoracic ultrasound (TUS) of ultrasonography on daily clinical practitioners. Topics discussed include use of TUS for the assessment of pleural effusions (PE), pneumothoraces, pneumonia, and lung cancer; the role of aetiology and chronicity of an effusion in variations in the TUS appearance of a PE; and the results showing that the echogenicity of a PE have low specificity for identifying an underlying exudate.

The article presents the management of Malignant Pleural Effusion (MPE) whose causes are evident of lung and breast cancers and are generally incurable and poor prognosis. Topics include the use of talc slurry pleurodesis or indwelling pleural catheters (IPCs), early tube removal by combining both IPC and talc pleurodesis, and the use of chemotherapy to prolong the life of patients.

BSTRACT The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91-95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy. [ABSTRACT FROM AUTHOR]

The article talks about identification of pleural fluid loculations through the lateral decubitus radiograph. Topics discussed include information collected from 86 patients who had a medical thoracoscopy with documentation of presence or absence of pleural adhesions; need to introduce a familiarity with the ultrasound machine and its interpretation in basic medical training, and comparison between Ultrasound-guided pulmonary biopsy and CT-guided biopsy.

The article discusses research being done on the management of malignant pleural effusion (MPE). It references the study "Pleurodesis Using Mistletoe Extracts Delivered via a Spray Catheter During Semi-Rigid Pleuroscopy for Managing Symptomatic Malignant Pleural Effusion," by J. S. Eom in this issue. Topics covered include the shortage of high-quality evidence on the therapeutic approach to MPE, the use of talc as chemical pleurodesis, and the anticancer effects of mistletoe extract.

No abstract available [ABSTRACT FROM AUTHOR]

No abstract available [ABSTRACT FROM AUTHOR]