Tuberculosis Pleural Treatment and Complications

Introduction to Tuberculosis Pleural

The American Thoracic Society recommends that tuberculosis pleural should not be left untreated, as the risk of progression to active pulmonary disease, tuberculous empyema, and severe fibrotic sequelae is significant, and 6-month antitubercular treatment is highly effective in preventing these complications 1

The use of corticosteroids, such as prednisone, does not prevent the development of residual pleural thickening in tuberculosis pleural, as demonstrated by two prospective, double-blind, randomized studies 1, 2
The study by Lee and associates found that although prednisone accelerated the resolution of symptoms and radiographic findings, it did not prevent pleural thickening 1
The study by Wyser and colleagues showed that the additional benefit of corticosteroids on symptoms was minimal, even when all patients had complete drainage of the effusion at the time of the diagnostic procedure 1

Pleural thickening is common in multiple infectious etiologies, not just tuberculosis, with an incidence of 86-100% in bacterial empyemas and 56% in exudative parapneumonic effusions 3, 4
In typical bacterial pleural infections, pleural thickening on contrast-enhanced CT is greater in those with frankly purulent effusions 3
The absence of pleural thickening indicates a simple parapneumonic effusion that likely does not require drainage 3

The American Thoracic Society recommends a 6-month regimen with isoniazid, rifampin, and pyrazinamide for 2 months, followed by 4 months of isoniazid and rifampin, as the treatment of choice for tuberculosis pleural 1

Empyema tuberculoso, a chronic and active infection of the pleural space containing a large number of tuberculous bacilli, generally occurs when a cavity ruptures into the pleural space and requires drainage (often surgical) in addition to antitubercular chemotherapy 1

Residual pleural thickening can resolve over several weeks in patients who avoid surgery 5
Residual calcification and thickening of extrapleural structures can persist as long-term sequelae 5
There is no evidence that atypical bacteria cause more fibrosis than tuberculosis; both can leave significant residual pleural thickening 3, 4