INDIAN JOURNAL OF MEDICAL SPECIALITIES 2011;2(2):144-146

Brief Communication
Tuberculous pleural effusion: clinico-radiological and biochemical features observed in an
Indian region
Anand Patel, Sushmita Choudhury

Abstract
Pleural effusion is one of the common manifestations of pulmonary tuberculosis. Knowledge of clinical,
radiological and pleural fluid analysis pattern of tuberculous pleural effusion may be specifically useful for
the Indian populace. This study was carried out to see the clinical, radiological and biochemical pattern of
tuberculous pleural effusion. A total of 53 patients of tuberculous pleural effusion were studied. Majority of
the patients were in the age group of 21-40 years. Commonest symptom was cough and onset was sub-acute.
Tuberculous pleural effusion was found to occur at a young age with no preference for either right or left side;
commonly affected less than two thirds of the hemithorax and was unaccompanied by pulmonary infiltrates in
three-fifths. Pleural fluid was generally lymphocyte-rich, exudative and high ADA levels were noticed.
Key words: Tuberculosis; Mycobacterium infections; adenosine deaminase.

Introduction
Tuberculosis is a common cause of pleural effusion,
especially in countries like India. Moreover
incidence of tuberculosis is increasing worldwide.
Tuberculous pleural effusion is thought to result
from a delayed hypersensitivity reaction which
occurs in response to the presence of mycobacterial
antigens in the pleural space. These mycobacterial
antigens may gain access to the pleural space from
the rupture of a small, subpleural caseous focus.
Tuberculous pleural effusion has been described as
an acute granulomatous pleuritis occurring as a
sequel to recent tuberculous infection in young
adults and children who usually do not have
roentgenographically apparent parenchymal
tuberculosis. However, it is now known that
tuberculous pleural effusion may occur in older
adults and in patients with classic reactivation
tuberculosis. With advent of HIV infection, the
epidemiology of tuberculous pleural effusion may be
changing. Diagnosis of pulmonary tuberculosis is
confirmed mainly by sputum examination of acid
fast bascilli (AFB), while the diagnosis of
tuberculous pleural effusion requires investigation
of pleural fluid biochemistry, cytology and pleural

biopsy. Positivity for AFB in pleural fluid and

histopathological (HP) study of pleura is very low
and culture is very time consuming. ELISA,
polymerase chain reaction (PCR) & Quantiferon are
expensive tests and not widely available. Definitive
diagnosis of tuberculous pleural effusion is often
difficult as in more than 50% of patients, pleura is
the only site of infection. Tuberculin test is nonspecific and can be negative. Because bacterial load
is less so pleural fluid culture for Mycobacterium
tuberculosis is also low (<20%). The present study
aimed to determine the clinico-radiological and
biochemical profile of tuberculous pleural
effusions.
Methods
This prospective observational study was carried
out in the Department of Tuberculosis & Respiratory
Diseases, Shree M. P. Shah Medical College, Guru
Gobindsing Hospital, Jamnagar, Gujarat from
January 2003 to December 2004. Adult patients of
either sex with pleural effusion underwent detailed
history and thorough clinical examination. They
were then subjected to detailed investigations
which included routine haemogram, urine

Department of Pulmonary Medicine, Smt. B. K. Shah Medical Institute & Research Centre, Sumandeep Vidhyapeeth, Piparia, Vadodara,
Gujarat, India.
Corresponding Author: Dr. Anand K. Patel, A/15, Krishnadeep Society, B/h Saurabh Park, Near Samta, Subhanpura, Vadodara 390021,Gujarat,
India. Email:dranandkpatel@gmail.com
Received: 24-2-2011| Accepted: 23-7-2011 | Published Online: 30-07-2011
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons.org/licenses/by/3.0)
Conflict of interest: None declared
Source of funding: Nil

144

Indian Journal of Medical Specialities, Vol. 2, No.2, Jul - Dec 2011

Tuberculous pleural effusion

examination, skiagram chest PA view, sputum smear

examination for AFB. Pleural fluid analysis was done
for protein, sugar, total cell count and differential
count in all patients. Pleural fluid cholesterol; LDH;
ADA and pleural fluid to serum ratio of protein; LDH;
cholesterol; bilirubin were done in selected
patients. Additional films, fluoroscopy,
ultrasonography, bronchoscopy, echocardiography
and other tests were performed, wherever
indicated. Pleural biopsy was done in selected
patients only in whom diagnosis was not derived in
spite of above means. Diagnosis was made on basis
of clinical examination, analysis of laboratory data
and response to anti-tubercular treatment (ATT)
according to Revised National Tuberculosis Control
Programme (RNTCP) guidelines. Pleural effusions
were classified as small (when fluid occupied < 1/3
of the hemithorax), moderate (when fluid occupied
>1/3 to < 2/3 of hemithorax) and large (when fluid
occupied > 2/3 of hemithorax). All patients
diagnosed as tuberculous pleural effusion
responded to ATT which were evaluated during
hospital stay and during follow up. A total of 53
patients were diagnosed as tuberculous pleural
effusion during the study period and were included
in the study.

and large effusion was present in 20.8% and 11.3%,

respectively. Forty three (81.1%) patients had free
fluid while 10 (18.9%) had encysted pleural
effusion. Twenty two (41.5%) patients had
associated parenchymal lesion. Ten (18.87%)
patients had associated ipsilateral pneumothorax
(hydropenumothorax). Out of 22 patients with
parenchymal lesion sputum for AFB was positive in
15 (68.18%) patients while out of 31 patients
without any parenchymal lesion it was positive in
only two (6.45%). Forty two (79.25%) patients had
straw coloured fluid while haemorrhagic and
purulent (empyema) was found in 9.44% and 11.31%
respectively. Turbidity (hazy fluid) was present in 48
(90.57%) of the patients. Cobweb and clot formation
was present in 18.87% and 15.09% respectively.
Pleural fluid protein was > 3gm/dL in 94.34%; sugar
was < 60mg/dL in 83.02%; cholesterol was > 60
mg/dL in 97.44%; LDH was > 200 IU/L in 97.44% and
ADA was > 40 IU/L in 96.67% of the patients.
Predominant lymphocyte count was found in 73.59%
of the patients. Pleural fluid total cell counts were
in the range of 0-250; 251-1000; 1001-5000 and
>5000 in 13.21%; 50.94%; 30.19% and 5.66% of the
patients respectively. Pleural fluid to serum ratio of
protein >0.5; bilirubin >0.6; cholesterol >0.3 and
LDH >0.6 was found in 100%; 76.67%; 100% and
86.67% of the patients respectively.

Results
Discussion
Out of 53 patients, 43 were males and 10 were
females. Mean age was 37.21 15.64 years. Majority
of the patients (56.6%) were in the age group of 2140 years. Five patients (9%) had past history of
pulmonary tuberculosis. Four (7.55%) patients were
having diabetes mellitus. Most common symptom
was cough (94.3%) followed by chest pain (71.7%)
while fever, anorexia, breathlessness and weight
loss were present in 64.15%, 64.15%, 58.5% and
49.1% of patients, respectively. Out of 31 patients
(58.5%) without parenchymal lesion, 30 had history
of cough; of which 19 (63.3%) had expectoration
while out of 22 patients with parenchymal lesion, 20
patients had cough; of which 19 (95%) had
expectoration. Majority of the patients had a subacute (67.9%) or chronic (22.6%) duration of
symptoms while only 9.4% had acute onset. Right
sided pleural effusion was present in 52.8%; left
sided was in 41.5% while only 5.66% had bilateral
pleural effusion. Mediastinal shift to opposite side
was present in 30.2%. Majority of the patients
(67.9%) had moderate pleural effusion while small
Indian Journal of Medical Specialities, Vol. 2, No.2, Jul - Dec 2011

Tuberculous pleurisy was once considered generally

to be a primary form of tuberculosis because it
usually occurred in children and young adults in
whom tuberculin skin test results had only recently
been positive rather than negative. In recent years,
it has been reported that mean patient age has
gradually risen [1] and that tuberculous pleurisy is
becoming a predominantly reactivated form of
tuberculosis.
Average occurrence of tuberculous pleural effusion
in the present study is similar to that in previous
studies [2,3] and considerably less than that
reported by some other authors [1]. Patients age is
of great diagnostic importance because in young
patients the presence of pleural exudates with a
high ADA concentration and a majority of
lymphocytes among its leucocytes is highly
suggestive of tuberculosis to the extent that pleural
biopsy may be superfluous [1]. The diagnosis of
tuberculous pleurisy in older patients is more
145

Anand Patel and Sushmita Choudhury

problematic because of the higher incidence of

clinically similar disorders, neoplastic effusions in
particular.
Furthermore, as noted above, in our region, the
presence of a pleural exudate with a high ADA
concentration and majority of lymphocytes among
its leucocytes makes pleural biopsy unnecessary if
the patient is young (< 35 years). This is partly
because of the high prevalence of tuberculous
pleuritis in this region, which increases the positive
predictive value and efficiency of ADA
concentration as a diagnostic marker [4]. In other
regions, the efficiency of this marker will not
necessarily be as high, and clinicians are
accordingly advised to determine this variable for
their own region.
In this study 41.51% of patients had tuberculous
pleural effusion accompanied by parenchymal
infiltrates. If the effusion was accompanied by
parenchymal infiltrates, sputum was the specimen
most likely to be positive for AFB smear. The sputum
was positive in 6.45% percent of cases without
infiltrates. In previously reported cases, largely
those of patients without infiltrates, there was
sputum positivity in only 11.11% of patients [2].
Although the yield of sputum AFB smear is low when
there are no parenchymal infiltrates, sputum for
AFB smear is simple to perform, without risk, and
should always be performed when tuberculous
disease is a diagnostic possibility.
The results of our pleural fluid analyses are also
consistent with those in previous reports. All 53
patients with pleural fluid analysis had exudative
effusions, 73.59% had predominant lymphocytic
effusion and 96.67% had pleural fluid ADA > 40 IU/L.
We conclude that in our region, the mean age of
patients with tuberculous pleural effusion is still

146

low with no tendency to occur preferentially on

either the right or the left side, and bilateral
effusions are uncommon. Moderated effusion is seen
most commonly while massive effusion is rare. The
effusions have the biochemical characteristics of
exudates with lymphocytic predominance and high
ADA is a characteristic marker.
Key Points

Tuberculous pleural effusions are common in

younger age group and commonly present with
mild to moderate effusion.

Pleural fluid is characteristically exudative,

lymphocytic predominant, with ADA levels > 40
IU/L.

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Indian Journal of Medical Specialities, Vol. 2, No.2, Jul - Dec 2011