Casalini pleurite tubercolare ttraduzido

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

• Pleurites parapneumônicas– pleurite simples– Derrame parapneumônico complicado e empiema

• Derrame pleural tubercular– pleurite– empiema (raro)

• Pleurites atípicas (frequentemente infecções oportunistas em P.tes imunodepressos)– fungos

• candida, aspergillo, criptococco, coccidioides, histoplasma, blastomyces, sporotrichosi

– Bactérias raras• Actinomicosi, nocardiosi, chlamidia, rickettsiae

– parasitas• Amebiasi, echinococcosi, paragonimiasi, trichominiasi

– virus (não se conhece a real epidemiologia!)• Adenovirus, hantavirus, cytomegalovirus, herpes virus, hepatite, mononucleose,

dengue.


Murray JF, Nadel JA Textbook of respiratory medicine. 2nd edition Philadelphia, W.B. Saunders, 1994; pp 1094-1160


1 Clinica: •pouco especifica

2 Radiologia: •Útil só se lesão parenquimal típicas e associadas

3 Mantoux:•Neg em 30% imunocompetentes•Neg em 60% imunodepressos

4 Laboratorio:•Ex..hematológicos: não úteis•Ex. citol. liquido: não discriminante•BK liq. pl.: sensibilidadede 10-35%


4 Laboratorio: markers

•Adenosine Deaminase (ADA)•lysozyme•Interferon-•Polymerase Chain Reaction (PCR)

Limites:•Poucos Laboratórios

•Custos elevados

•Falsos positivos e negativos

•BK resistentes (Exame cultural indispensável!!)


• the ability to predict the presence or absence of disease from ADA test results is dependent on the prevalence of the disease in the population tested, as well as on the sensitivity and specificity of the test

• a limitation of the test in this setting, as a sole method of diagnosis, is that culture results will not be available to guide antituberculosis chemotherapy

• patients with drug-resistant tuberculosis may receive treatment with inefficient drugs due to the lack of availability of culture and drug-sensitivity results

• therefore, an increased ADA level should not be considered as an equivalent to the presence of mycobacteria in the pleural fluid or pleural biopsy specimens


GOLD STANDARD

1. Isolamento do BK

a) Líquido pleurico

b) Escarro ou broncoaspirado

c) Biópsia

2. Exame histológico

a) Biópsia transcutânea

b) Biópsia toracoscópica


70 pacientes4.9% di 1738 casos de tbc

35 lesões parenquimatosas

35 não lesões parenquimatosas

Seilbert AF. Tuberculous pleural effusions: Twenty year experience. Chest 1991; 99:883.

2 Radiologia: •útil só se lesões pulm. típicas associadas

escarro + 31/35 (89%)

escarro + 4/35 (11%)



71/84 (84%) versamento linfocitario (linfociti > 80%)

AFB smear Culture of M. Tb

No parenchymal lesions (64 Pts)

11% (7/64) 54% (35/64)

With parenchymal lesions (20 Pts)

15% (3/20) 45% (9/20)

Cerca de50% dos pacientes com pleurite TBC eliminam BK com escarro: epidemiológicamente relevante!!!


Imaging

Toracocentese

Laboratório



Diagnostic pleural fluid sampling is recommended in all patients with a pleural effusion >10 mm depth in association with a pneumonic illness or who have features of ongoing sepsis.

Imaging guidance should be used since this minimises risks of organ perforation and improves the recovery rate of pleural fluid. Sampling using thoracic ultrasound is simple, safer and will reduce patient discomfort.

Small effusions (ie, <10 mm thickness) will usually resolve with antibiotics alone. Observation may be appropriate for these patients, but an increase in the size of the effusion or ongoing sepsis should warrant re-evaluation and diagnostic pleural fluid sampling.

Imaging

Toracocentese

Laboratorio


in 95.2% of the TPE (157/165) the percentage of lymphocytes was 50%

only 1 TPE had a lymphocyte percentage count 32%.

95% (20/21) of the infectious effusions had more than 50% neutrophils

only 1.8% (3/165) of the TPE.

only 4 patients (3 TPE and 1 infectious) had 10% eosinophils.


TPE = tuberculous pleural effusion

TB

Large B-Cell Lymphoma

chylothoraxU.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

•Tuberculous pleuritis is a treatable cause of a lymphocytic pleural effusion.

•It is desirable to exclude the diagnosis in patients with lymphocytic effusions, avoiding inappropriate and side effect-prone empirical antituberculous therapy.

•In patients who are unfit for invasive investigations, pleural fluid or blood biomarkers of infection can be useful.


N.B.

• 40 pacientes

• 14 Mulheres (5 EC): media de idade 43 (18-74)• 26 Homens (15 EC): media de idade 45 (21-75)

Realizado Toracoscopia em 36/40


*dati personali non pubblicati

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica *dados pessoais não publicados.

0

1

2

3

4

5

6

7

8

9

< 30 31-40 41-50 51-60 > 61

non-EEC

italians

direto cultura

Liquido pleurico 3 (PCR) 2/16 = 12,5%

Escarro 1 /15 = 6,6%

FBS 3(1 direto, 2 PCR) 5*/16 = 31%

Toraco** (13) 1 direto

2 PCR

6/13 = 46% (biópsia e fibrina)

*nos 2 pacientes que fizeram a toraco a cultura da biópsia foi negativa

** Realizado Toraco em 13/16 pacientesU.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

direto cultura

Líquido pleurico

3 PCR 2/24 = 8,3%

Escarro nunca

FBS Nunca (não realizado ou negativo)

Toraco* (23) 1 Direto

3 PCR

14/23 = 60%(biópsia e fibrina)

*Realizaado toraco em 23/24 pacientes


Resultados sem a Toracoscopia

Diagnóstico em 11/40 pacientes = 27,5%

Em 6 dos quais o diagnóstico só com exame cultural depois de 30 dias

Em 29 pacientes teriam colocado o diagnóstico de

“pleurite inespecífica”U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Riscos por falta de diagnóstico de uma pleurite tubercular

35%: cura espontânea

92/141 (65%): desenvolvem TBC pulmonar ou extrapulmonar em 5 anos

WH Roper, JJ Waring. Primary serofibribous pleural effusion in military personel. Am Rev Tuberc Pulm Dis 1955; 71:616-634.

Indispensável o diagnóstico de certezaPara iniciar um tratamento correto


Tuberculous pleural effusions

Therapy Resolution time

No therapy 2-4 mo

INH, rifampin 2 mo

INH, rifampin,PZA 1-2 mo

Addition of prednisone 1-2 mo


Engel ME, Matchaba PT, Volmink J. Corticosteroids for tuberculous pleurisy. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001876. DOI: 10.1002/14651858.CD001876.pub2.

• There are insufficient data to support evidence-based recommendations regarding the use of adjunctive corticosteroids in people with tuberculous pleurisy.

• Randomized controlled trials that are sufficiently powered to evaluate the effects of corticosteroids on both morbidity and mortality are needed.

• The effects of corticosteroids on HIV-related complications, such as Kaposi sarcoma, should be assessed in people co-infected with HIV.

http://www.thecochranelibrary.com/


Conclusões

• Necessidade de um diagnóstico correto e precoce

• Limites do diagnósstico clínico e de laboratório• Metodologia de biópsia

– Com a toracoscopia: diagnóstico em quase 100%• è um exame relativamente facil;• A invasão é limitada, e efeitos colaterais limitados• Pode confundir com outras causas de derrame pleural

Casalini pleurite tubercolare ttraduzido

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