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The Relationship between Pleural Fluid Findings and the Development of Pleural
Thickening in Patients with Pleural Tuberculosis

Article  in  Chest · December 1991

DOI: 10.1378/chest.100.5.1264 · Source: PubMed

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 The relationship between pleural fluid findings
and the development of pleural thickening in
patients with pleural tuberculosis.
C S Barbas, A Cukier, C R de Varvalho, J V Barbas Filho and R W Light

Chest 1991;100;1264-1267
DOI 10.1378/chest.100.5.1264
The online version of this article, along with updated information and services
can be found online on the World Wide Web at:
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© 1991 American College of Chest Physicians
The Relationship between Pleural Fluid
Findings and the Development of Pleural
Thickening in Patients with Pleural
Tuberculosis*
Carmen S. V Barbas, M.D.; Alberto Gukier, M.D.;
Carlos R. R. de Varvaiho, M.D.; Jodo % Bar/xis Filho, M.D.; and
RichardWLight, M.D., FG.G.P

The objective of the study was to determine if residual was 5.40±0.58 g/dl for group 1 and 5.17±0.80 g/dl for
pleural thickening after treatment for pleural tuberculosis group 2, while the mean pleural fluid glucose level was
could be predicted from the pleural fluid findings at the 78.6± 19.5 mg/dl for group 1 and 79.5±20.1 mg/dl for
time of the initial thoracentesis. Forty-four patients initially group 2. The
pleural mean
fluid lactate dehydrogenase
diagnosed as having pleural tuberculosis between January (LDH)level in group 1 was 593 ±498 lUlL, while the mean
1986 and January 1988 were separated into two groups: the level for group 2 was 491 ± 198 lUlL. The presence of
23 patients in group 1 had residual pleural disease, while residual pleural thickening was not related to the chemo-
the 21 patients in group 2 had no residual pleural disease therapeutic regimen or the performance of a therapeutic
after treatment for their pleural tuberculosis was corn- thoracentesis. From this study we conclude that approxi-
pleted. Tb. clinical characteristics of the two different mately 50 percent of patients with pleural tuberculosis will
groups did not differ significantly, but the patients in group have residual pleural thickening when their therapy is
1 tended to be a little sicker in that the duration of their completed, but that one cannot predict which patients will
symptoms was longer, their hemoglobin values were lower, have residual pleural thickening from either their clinical
and weight loss and cough were more frequent. There were characteristics or their pleural fluid findings.
no significant differences in the pleural fluid findings in the (Chest 1991; 100:1264-67)
two different groups. The mean pleural fluid protein level

A sizable percentage of patients who have pleural tuberculosis

of Medicine
were
ofthe
seen
University
at the Hospital
of Sao Paulo
das Clinicas
(Brazil).
of the
All patients
Faculty
who
tuberculosis have residual pleural thickening af-
had either a pleural biopsy specimen showing granulomas with
ter treatment for the tuberculosis is completed. ‘ The
caseous necrosis and/or pleural fluid or pleural tissue positive on
incidence of residual pleural thickening appears to be culture for Mycobacterium tuberculosis were included in the study.
largely independent of the treatment,”3 although one Forty-four patients returned to follow-up after 6 to 12 months and
report suggests that the administration of corticoste- these patients form the study population.
Prior to treatment, the following data were obtained: patient’s
roids decreases the incidence of residual pleural
age; duration of symptoms; presence or absence of fever, weight
thickening2 and another suggests that a therapeutic loss, chest pain, night sweats, dyspnea, and cough; reaction to
thoracentesis decreases the incidence ofresidual pleu- intradermal purified protein derivative (PPD); level of protein,
ral thickening. glucose, LDH, and amylase in the pleural fluid; level of protein,
We hypothesized that those patients who had the glucse, and LDH in the serum; cellular composition ofthe pleural
fluid; and the size of the effusion. The effi,sion was classified as
greatest amount of pleural inflammation as evidenced
large if on the posteroanterior chest roentgenogram the effusion
by the highest levels oflactate dehydrogenase (LDH)
occupied more than one third the distance between the lateral
and the lowest levels of glucose in the pleural fluid chest wall and the medlastinum at the level of the hilar region.’ In
would he those most likely to develop residual pleural addition, the histologic features and culture results of the pleural
thickening. In this retrospective study of 44 patients, biopsy specimen and the culture results of the pleural fluid were
recorded.
the occurrence of residual pleural thickening was
During the study period, several different treatment regimens
correlated with the pleural fluid findings at the time for pleural tuberculosis were used. Fourteen patients received
of the initial thoracentesis. isoniazid, rifampin, and pyrazmnamide for the initial two months
followed by an additional seven months of therapy with isoniazid
MATERIALS AND METHODS and rifampin. Twelve patients received isoniazid and rifampin for
Between January 1986 and January 1988, 71 patients with pleural nine months and an additional 12 patients received isoniazid,
rifampin and pyrazinamide for the initial two months followed by
5Fmm the Lung Unit, Faculty ofMedicine, University ofSao Paulo, four additional months of isoniazid and rifampin therapy. Four
Brazil, and the Department of Medicine, Veterans Administration patients received rifampin, ethaunbutol, and isoniazid for three
Medical Center, Long Beach, Calif. and the University of Califor- months, ethambutol and isoniazid for another three months, and
nia, Irvine.
isoniazid alone for an additional three months. Two patients received
Manuscript received December 20; revision accepted March 12.
Reprint requests: Dr. Light, Chief of Research (151), VA Medical other regimens. Eleven patients underwent therapeutic thoracen-
Center, Lirng Bead, 90822 tesis of more than 500 ml. No patient received corticosteroids.

1264 Pleural Auid, Pleural Thkon#{232}ngand Pleural Tuberculosis (Bathes et a!)

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© 1991 American College of Chest Physicians
 Table 1-Comparison OJC1InICa1 Characteristics in Table 2-Comparison ofRoentgenographic and Pleural
Patients with Residual Pleural Thickening (Group 1) and Biopsy Findings in Patients with Residual Pleural
Those without Pleural Thickening (Group 2) Thickening (Group 1) and Those without Pleural
Thickening (Group 2)
Group!, Gro#{252}p2,
No. (%) No. (%) Group 1, Group 2,
No. (%) No. (%)
Age, yr. mean±SD 35.8±13.1 34.8± 14.3
Hemoglobin, gIdl 12. 1 ± 1.9 12.4 ± 1.2 PPD >15 mm induration 11/15 (73) 8/16 (50)
Duration ofsymptoms, 8 wk* 6/14 (43) 2110 (20) Large pleural effusion 1L/23 (48) 6/21 (29)
Fever 21/23 (91) 20/21 (95) Parenchymal lesion also 5/23 (22) 5/21 (24)
Weight loss 19/23 (83) 15/21 (71) Positive pleural fluid culture 2/19 (11) 5/12 (42)
Chest pain 21123 (91) 20/21 (95) Positive pleural lx culture 15(19 (79) 11114 (79)
Night sweats 12/23 (52) 11121 (52) Granuloma pleural Bx 20/22 (91) 16/18 (89)
Dyspnea 15/23 (65) 13/21 (62) AFB on pleural Bx 7/22 (32) 10/18 (56)
Cough 16/23 (70) 12121 (57) Necrosis on pleural Bx 7/20 (35) 8118 (44)

*Data unavailable for nine patients in group 1 and 11 patients in

Dx with first Bx 17/22 (77) 19/21 (90)
Therapeutic thoracentesis 3 (22) 6t21 (29)
group 2.
INH + Rif+ PZA (6 mo) 5/23 (22) 7/21 (33)
INH + Rif± PZA (9 mo) 18123 (78) 14121 (67)
The 44 patients were separated into two groups based on their
chest roentgenograms at the end of treatment (6 to 12 months after *PPD =purified protein derivative; Bx=biopsy; AFB acid-fast
the diagnosis depending on the therapeutic regimen). The 23 bacilli; Dx = diagnosis; INH isoniazid; Rif rifampin; and
patients in group 1 had residual pleural thickening that was defined PZA= pyrazinamide.
as a pleural thickening greater than 2 mm on the lateral-inferior
portion ofthe posteroanturior chest roentgenogram. The 21 patients fluid cultures and a lower incidence of positive acid-
in group 2 had no such thickening.
fast bacilli (AFB) smears. The patients whose final
Statistical Analysis evaluation occurred after six months of therapy had
The data are expressed as the mean ± the standard deviation
no higher incidence of pleural thickening than did
unless otherwise noted. The pleural fluid protein, LDH, and glucose those whose evaluation occurred after nine or more
levels and the ratio ofthe pleural fluid to serum protein, LDH, and months oftherapy. Likewise, the incidence of residual
glucose levels in the 23 patients with residual pleural thickening pleural thickening did not appear to be related to the
and the 21 patients without residual pleural thickening were
chemotherapeutic regimen or whether the patient had
compared with the unpaired t test. The percentage ofpatients with
various clinical characteristics or receiving different treatment received a therapeutic thoracentesis.
regimens in the two different groups were compared with the x5 There appeared to be no relationship between
test. residual pleural thickening and the level of protein,
glucose, or LDH in the pleural fluid at the time of the
RESULTS
initial thoracentesis. The mean protein and LDH
The clinical characteristics of the 23 patients with
and the 21 patients without residual pleural thickening
were quite similar (Table 1). The mean ages and
7.0 -

hemoglobin levels were nearly identical in the two .

groups. There was no significant difference in the z
fraction of patients with fever, weight loss, chest pain,
night sweats, dyspnea, or cough in the two different
groups, although the group that was left with residual
thickening
symptoms and slightly
did have a slightly
higher incidence
longer duration
ofweight
of
loss !.. 6.0
S.
S

and cough. Although more than 50 percent of the S.

study population had residual pleural thickening at .I $I

S
the last follow-up visit, the pleural thickening itself S
did not appear to be responsible for symptoms at this S
visit in any of the patients. S
The skin test results, roentgehographic findings, and
pleural biopsy and culture results did not differ
signfficantly between the two different groups (Table
2). The patients with residual pleural thickening
tended to have a higher incidence of a PPD with PLEURAL NO PLEURAL
greater than 15 mm induration and tended to have a THICKENING THICKENING
higher incidence of large pleural effusions, but they Ficuis 1. Levels of pleural fluid protein in patients with and
tended to have a lower incidence of positive pleural without residual pleural thickening.

CHEST I 100 I 5 I NaVEMBER, 1991 1265

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© 1991 American College of Chest Physicians
 S S thickening when chemotherapy is completed for pleu-
ral tuberculosis. The incidence of residual thickening
does not appear to be related to the initial biochemical
findings in the pleural fluid or the clinical character-
S
S istics of the patients at the time of presentation.
I 00-
S.
Moreover, the incidence of residual thickening was
w $ S not related to the chemotherapeutic regimen or the
0 S. $ performance of a therapeutic thoracentesis. In one
0 S..
C) S
previous report, patients who had undergone thera-
80 - -
peutic thoracentesis had a significantly lower mci-
-J .
0 $ S dence of residual pleural thickening.
We had hypothesized that those individuals who
00
S I had lower pleural fluid glucose levels or higher pleural
-JE 60 S5 5 fluid LDH levels would be niore likely to have residual
L& S
S pleural thickening. The leyel of pleural fluid LDH is
..J
S
thought to be correlated with the degree of pleural
S
inflammation.6 Certainly in patients with parapneu-
w 40 monic effusions, the lower the pleural fluid glucose
-J
0. S level or the higher the pleural fluid LDH level, the
more likely that the patient is to require chest tubes.7
Furthermore, a low pleural fluid glucose level in
patients with malignant pleural effusions is associated
I I
with a large tumor burden.8 However, the data from
PLEURAL NO PLEURAL
THICKENING THICKENING our study offered no support for our hypothesis.
In the present study, there was no relationship
Ficuax 2. Levels of pleural fluid glucose in patients with and
without residual pleural thickening. between the treatment that the patient received and
residual pleural thickening. When one reviews the
levels were slightly higher while the mean pleural natural history of untreated tuberculous pleuritis, one
fluid glucose level was slightly lower in patients with
‘: .2563
residual pleural effusions. The distribution of the
values for the pleural fluid levels of protein (Fig 1), 1 ooo_:
glucose (Fig 2) and LDH (Fig 3) were virtually
identical in the two different groups. S
The mean ratio ofthe pleural fluid to serum protein
level was similar in the group with thickening 800-
S
S
(0.72±0.08) and the group without thickening
(0.72 ± 0. 10). Likewise, the ratio ofthe pleural fluid to
serum glucose and LDH were similar in the groups
a S
S
S
with thickening (0.76±0.25 and 2.58± 1.70, respec-
-J 600- 2 S
tively) and without thickening (0.85±0.17 and
S
D
2.74 ± 1 .33, respectively). S 1
S
The data were also analyzed to determine if there S
I
was a significant relationship between the levels of 0 .5 S
S
glucose and LDH in the pleural fluid of the entire -J 400 -

S
group of patients. There was a significant relationship S #{149}5
between the ratio ofthe pleural fluid to serum glucose S. S
S
S
and the ratio of the pleural fluid to serum LDH .5 S
(r = - 0.51, p<O.Ol). The minus sign on the correlation 200- 5 S

coefficient indicates that low glucose levels are asso-

ciated with high LDH levels. There were no signfficant
correlations among the absolute levels of protein,
glucose, and LDH in the pleural fluid.
I ‘
PLEURAL NO PLEURAL
DISCUSSION
THICKENING THICKENING
The present study demonstrates that there is ap- Ficuax 3. Levels of pleural fluid lactate dehydrogenase (LDH) in
proximately a 50 percent incidence of residual pleural patients with and without residual pleural thickening.

1266 Pleural Auid, Pleural Thickenrng and Pleural Tuberculosis (Bathes eta!)

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© 1991 American College of Chest Physicians
should not be surprised at this finding. Roper and the changes in pulmonary function with residual
Waring#{176}followed 141 individuals who had exudative pleural thickening were not documented in this or in
pleuritis and a positive skin test to PPD. The patients, previous studies, patients with asbestosis and much
who were first diagnosed in 1944 or 1945, were treated greater amounts of pleural thickening have only mild
only with bed rest. At the end of their initial hospital- reductions in their pulmonary function test
ization, only 48 (34 percent) had more than slight
residual pleural thickening. Since residual pleural ACKNOWLEDGMENTS: We thank the following physicians who
took care of the patients in the Ambulatory Clinic of Tuberculosis
disease from tuberculosis tends to improve with time,2 of the Hospital das Clinicas-Faculty of Medicine-University of San
we thought that those patients who were evaluated Paulo: Eliane C. R. Follador, Fernanda M. V. Boueri, Loavo M.
Leite, Teresa Y. Takagaki, and Ronaldo A. Kairalla. We thank Marina
after six months of therapy might have a higher Berman for her assistance with the medical illustrations.
incidence of residual pleural thickening than those
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CHEST I 100 I 5 I NOVEMBER, 1991 1267

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© 1991 American College of Chest Physicians
 The relationship between pleural fluid findings and the development of
pleural thickening in patients with pleural tuberculosis.
C S Barbas, A Cukier, C R de Varvalho, J V Barbas Filho and R W Light
Chest 1991;100; 1264-1267
DOI 10.1378/chest.100.5.1264
This information is current as of July 10, 2011
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