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ORIGINAL ARTICLE
Year : 2007  |  Volume : 24  |  Issue : 1  |  Page : 17-19 Table of Contents   

Use of fibreoptic bronchoscopy in increasing diagnostic yield in smear negative tubercular pleural effusion


Department of Tuberculosis and Respiratory Diseases, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana)., India

Correspondence Address:
K B Gupta
6J/18, Medical Enclave, Pt. B.D. Sharma PGIMS, Rohtak-124001 (Haryana).
India
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DOI: 10.4103/0970-2113.44197

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   Abstract 

Setting: Department of Tuberculosis and Respiratory diseases, Pt. B.D. Sharma PGIMS, Rohtak.
Aim: Study was carried out to evaluate the diagnostic yield of fibreoptic bronchos­copy in patients of smear negative tubercular pleural effusion.
Methodology: Flexible fibreoptic bronchoscopy under local anaesthesia was car­ried out and bronchoalveolar lavage was stained by Z-N staining for AFB and en­dobronchial biopsy was sent for histopathological examination and direct staining for AFB.
Results: Endobronchial abnormalities were visualised in nearly 50% cases in right sided pleural effusion and 38% cases in left sided pleural effusion. Bronchoalveolar lavage was positive for AFB in 8% of cases. Endobronchial biopsy for histopathol­ogy and staining for AFB was positive in 12% of cases.
Conclusion: Flexible fibreoptic bronchoscopy is very safe and novel technique in increasing bacteriological yield of patients with tubercular pleural effusion.

Keywords: Tubercular pleural effusion, Fibreoptic bronchoscopy


How to cite this article:
Gupta K B, Chopra P. Use of fibreoptic bronchoscopy in increasing diagnostic yield in smear negative tubercular pleural effusion. Lung India 2007;24:17-9

How to cite this URL:
Gupta K B, Chopra P. Use of fibreoptic bronchoscopy in increasing diagnostic yield in smear negative tubercular pleural effusion. Lung India [serial online] 2007 [cited 2014 Nov 27];24:17-9. Available from: http://www.lungindia.com/text.asp?2007/24/1/17/44197


   Introduction Top


Tuberculosis remain one of the most important health problems in India. Presently one third of world population is infected with M. Tuberculosis. [1] Pleural tuberculosis is a common form of extrapulmonary tuberculosis only next to lymphnode tuberculosis [2] . Demonstration of acid fast bacilli in sputum, body fluid or tissue is golden diagnostic test for tuberculosis. However, sputum smear examination and culture for mycobacterium is positive only in 4-11% of patients with tubercular pleural effusion. [3],[4] Direct smear examination of pleural biopsy specimen for AFB is positive in around 18% of cases. Although yield of pleural biopsy specimen culture for AFB is around 55 to 80%, 2 but culture reports take time and it seems unjustifiable to wait for initiation of ATT.

Because of these reasons, most of the patients with tubercular pleural effusion are put on antitubercular treatment empirically on the basis of clinical history, predominance of lymphocytes in pleural fluid and histopathological examination of pleural biopsy tissue. Though these are highly sensitive investigations, but lymphocytic pleural effusion and granulomatous pleuritis can be present in a number of other conditions also. So patients with other etiologies can be wrongly misclassified as tubercular pleural effusion, causing delay in appropriate treatment of underlying condition with catastrophic outcome in some such as malignancy. Fibreoptic bronchoscopy is a useful diagnostic modality for identification of infectious agents in both immunocompromised and immunocompetent host and has shown good results in diagnosis of smear negative pulmonary tuberculosis [5],[6],[7] . Therefore present study was planned to evaluate the use of fibreoptic bronchoscopy in increasing diagnostic yield in tubercular pleural effusion.


   Material and Methods Top


Fifty cases of suspected tubercular pleural effusion during the period from August 2004 to Feb. 2006 in the Department of Tuberculosis and Respiratory Diseases, Pt. B.D. Sharma PGIMS, Rohtak were taken into the study. Consecutive cases of pleural effusion including both males and females with possible tubercular etiology, either unable to produce sputum or sputum sample negative for AFB on 3 consecutive occasions were taken into study. The study was approved by Postgraduate board of studies, Medicine and allied sciences, PGIMS, Rohtak as a research topic. Patients who were found positive for AFB on sputum microscopy were excluded from study. Patients who had clinically or radiological evidence of renal diseases, cardiac diseases, lung cancer, liver failure, pregnancy, hypoprotinemia, positive for serological test for human immunodeficiency virus or if they had received antitubercular therapy were excluded from the study.

Skiagram chest, hemoglobin, total and differential leucocyte counts, erythrocyte sedimentation rate, urine complete examination, blood for serological testing for human immune deficiency virus, ultrasonography of thorax and abdomen, computerised tomography of chest was carried out in all the patients. Thoracocentesis and pleural biopsy was done in all the patients and pleural fluid was sent for biochemical, cytological examination and staining and for AFB smear examination. Pleural biopsy specimens were sent for histopathological examination and direct smear examination for AFB.

All the patients were divided into 2 groups Group I confirmed cases of tubercular pleural effusion in whom AFB was present in pleural biopsy specimen or histopathology of pleural biopsy is confirmatory (presence of caseating granuloma). Group II suspected cases of tubercular pleural effusion includes who were having fever, breathlessness, chest pain, night sweats, loss of appetite, positive tuberculin skin test, exudative pleural effusion and presence of predominantly lymphocytes on pleural fluid cytology. They consecutively responded well to short course antitubercular treatment for 6 months.

Flexible fibreoptic bronchoscopy was carried out in all the patients and bronchoalveolar lavage was sent for AFB and endobronchial biopsy was sent for histopathological examination and direct smear examination for AFB (where endobronchial nodular abnormalities were visualized). All the cases were put on antitubercular treatment with regular follow up every 2 monthly till 6 months and response to treatment was noted.


   Results Top


Total 50 cases of tubercular pleural effusion were taken into study (33 males and 17 females) with mean age of 32 years. 30 patients (60%) had right sided pleural effusion and 20 patients (40%) had left sided pleural effusion.

Out of 50 cases, 23 patients were confirmed cases of tubercular pleural effusion in whom histopathology of pleural tissue or /and direct smear examination of pleural biopsy specimen was positive for AFB (Group I), while 27 patients were put on antitubercular treatment on clinical suspicion or/and supportive findings such as positive tuberculin test, lymphocytic pleural effusion (Group II).

Findings of FOB

In right sided pleural effusion most common visual endobronchial abnormality was hyperemia and hemorrhagic oozing from lower lobe bronchus opening followed by nodular abnormalities in bronchus. Endobronchial abnormality were found in 50% of patients. Endobronchial abnormality was present in contralateral lung (left side) in 4 patients (13%) in the form of hyperemia and oozing in main bronchus opening [Table 1].

In left sided pleural effusion, similar endobronchial abnormalities were observed such as hyperemia, hemorrhagic oozing and nodular abnormalities in left lower lobe bronchus. Endobronchial abnormalities were present in 38% of cases. Endobronchial abnormalities were also found in contralateral lung (right side) in 2 patients (10%) [Table 2].

Direct smear examination of bronchoalveolar lavage for AFB was positive in 2 patients and endobronchial biopsy was consistent with finding of tuberculosis in 4 patients in Group I. Thus yield of fibreoptic bronchoscopy is (26%) in Group I [Table 3]. Direct smear examination of bronchoalveolar lavage and endobronchial biopsy is positive in 2 patients each in (Group II). Thus yield of FFOB in this group is comparatively low that is (14%). Collective yield of FFOB for both groups is 20% [Table 3]. The procedure was found very safe and no patient had any complication during and after the procedure. All the patients responded very well both clinically and radiologically to treatment.


   Discussion Top


Tubercular pleural effusion is categorised as extrapulmonary disease despite an intimate anatomical relationship between pleura and lung. The exact incidence of tubercular pleural effusion is not known in India, but there has been an increasing incidence in United States and this has been ascribed to the epidemic of human immuno deficiency virus infection (HIV). Therefore we expect that incidence of pleural effusion in India must be rising [8] . Various studies reported that patients with tubercular pleural effusion usually have associated parenchymal lesions. These parenchymal lesions are usually not evident on chest skiagrams, but CT thorax can delineate underlying lung consolidation and other parenchymal lesions in large number of patients [9],[10] . This reflects that tubercular pleural effusion is usually post primary tuberculosis specially in adults. Rupture of these subpleural parenchymal tubercular focus and shedding of AFB in pleural space might have taken place, leading to development of pleural effusion in these patients.

Despite the presence of parenchymal lesions in large number of patients with tubercular pleural effusion, sputum and pleural fluid examination for AFB is usually negative. Yield can be increased by use of sputum induction, which is non invasive method or by use of fibreoptic bronchoscopy. In present study with the help of bronchoscopy we could able to confirm 20% of cases by using simple techniques such as direct smear examination of bronchoalveolar lavage (8%) and Z-N staining of endobronchial biopsy tissue (12%) while endobronchial lesions were visualised in around 50% of cases. Diagnostic yield can be increased by use of modern diagnostic techniques such as DNA amplification like PCR (polymerase chain reaction) on bronchoalveolar lavage samples.

Thus the present study concludes that fibreoptic bronchoscopy is a very safe and novel technique in increasing diagnostic yield in patients with tubercular pleural effusion, who are either not able to produce sputum or in whom sputum smear examination for AFB is negative.

 
   References Top

1.Dye C, Schede S, Dolin P, Pathania V, Ragivlione MC. Global burden of tuberculosis estimated incidence, prevelance and mortality by country. JAMA 1999; 282: 677-96.  Back to cited text no. 1    
2.Berger HW, Meha E. Tuberculous pleurisy. Chest 1973; 63: 88­-92.  Back to cited text no. 2    
3.Seiberg AF, Haynes J Jr., Middleton R, Bass JB. Tuberculous pleural effusion. Twenty year experience. Chest 1991; 99:883-6.  Back to cited text no. 3    
4.Epstein DM, Kline LR, Albelda SM, Miller WT. Tuberculous pleural effusion. Chest 1987;91: 106-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Willcox PA, Benatar SR, Potgieter PD. Use of flexible fibreoptic bronchoscopy in diagnosis of sputum negative pulmonary tuberculosis. Thorax 1982; 37: 598-601.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Ip M., Chau PY, So SY, Lam WK. The value of routine bronchial aspirate culture at fibreoptic bronchoscopy for the diagnosis of tuberculosos. Tubercle 1989; 70: 281-5.  Back to cited text no. 6    
7.Jett JR, Cortese DA, Dines DE. The value of bronchoscopy in the diagnosis of mycobacterial disease. Chest 1981; 80(5): 575-8.  Back to cited text no. 7    
8.Tuberculosis in New York City 1992. New York: Bureau of Tuberculosis Control. New York City Department of Health 1993.  Back to cited text no. 8    
9.Hulnick H, Naidich P, McCauley L. Pleural tuberculosis evaluation by computed tomography. Radiology 1983;149: 759-65.  Back to cited text no. 9    
10.Lee KS, Song HS, Lim TH, Kim PN, Kim Y, Lee BH. Adult onset pulmonary tuberculosis. Findings on chest radiographs and computed tomography scan. Am J Roentgenol 1993; 160: 753-7.  Back to cited text no. 10    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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