Department of Pulmonary Medicine, Yashoda Superspeciality Hospitals, Somajiguda.
Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.
J Bronchology Interv Pulmonol. 2023 Oct 1;30(4):354-362. doi: 10.1097/LBR.0000000000000887.
Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous necrosis, and adhesions have been described in TPE. However, none of these have high specificity for diagnosing TPE. In this study we evaluate a novel finding on thoracoscopy, the " Pleural Pustule."
This is a retrospective analysis of patients who underwent thoracoscopy for undiagnosed pleural effusion. Visual inspection of the pleura was performed to identify abnormalities. Biopsies were obtained from those areas and sent for histopathology, acid fast bacillus (AFB) smear, culture, and Xpert MTB/Rif assay. Pleural pustule was defined as a pus filled nodule on the pleural surface.
Of the 259 patients included, 92 were diagnosed with TPE. Pleural pustule(s) were identified in 16 patients with TPE. Presence of pleural pustule had a sensitivity, specificity, positive predictive value, and negative predictive value of 17.4%, 100%, 100% and 68.7%, respectively, for diagnosing TPE. Histopathology of pleural pustule demonstrated necrotizing granulomas in all. In patients with pleural pustule, a microbiological diagnosis of tuberculosis was achieved in 93.7% patients (AFB smear, Xpert MTB/Rif assay, and MTB culture positive in 31.3%, 93.7%, and 43.7% cases, respectively). There is a strong association between pleural pustule and positive Xpert MTB/Rif assay ( P =0.002) and microbiologic confirmation of diagnosis ( P =0.017).
The presence of pleural pustule on thoracoscopy has a high positive predictive value for TPE. In tuberculosis-endemic countries, this can be considered suggestive for TPE. When identified, a biopsy from the pleural pustule should be performed as it will likely yield a positive microbiologic diagnosis.
胸腔镜胸膜活检是诊断结核性胸腔积液（TPE）的金标准。在 TPE 中已经描述了各种胸腔镜表现，如西米状结节、干酪样坏死和粘连。然而，这些都没有很高的特异性来诊断 TPE。在这项研究中，我们评估了胸腔镜检查中的一个新发现，即“胸膜脓疱”。
这是一项对因不明胸腔积液而行胸腔镜检查的患者进行的回顾性分析。对胸膜进行肉眼检查以识别异常。从这些区域获取活检并进行组织病理学、抗酸杆菌（AFB）涂片、培养和 Xpert MTB/Rif 检测。胸膜脓疱定义为胸膜表面充满脓液的结节。
在 259 例患者中，92 例诊断为 TPE。在 16 例 TPE 患者中发现了胸膜脓疱。胸膜脓疱的存在对 TPE 的诊断具有 17.4%的敏感性、100%的特异性、100%的阳性预测值和 68.7%的阴性预测值。胸膜脓疱的组织病理学显示均为坏死性肉芽肿。在有胸膜脓疱的患者中，93.7%的患者（AFB 涂片、Xpert MTB/Rif 检测和 MTB 培养阳性率分别为 31.3%、93.7%和 43.7%）的微生物学诊断为结核病。胸膜脓疱与 Xpert MTB/Rif 检测阳性（P=0.002）和微生物学确诊之间存在很强的关联（P=0.017）。
胸腔镜检查时出现胸膜脓疱对 TPE 具有很高的阳性预测值。在结核病流行的国家，可以认为这是 TPE 的提示。当发现胸膜脓疱时，应进行胸膜脓疱活检，因为它可能会产生阳性的微生物学诊断。
