Tuberculosis, Pleural (TB Pleurisy)
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
A16.5 + (B20.0)
DESCRIPTION
TB pleurisy presents with a few weeks of pleuritic pain; often associated with a dry cough, fever, night sweats, weight loss, and, with large effusions, progressive shortness of breath.
Diagnosis
- It is essential to perform a diagnostic tap of pleural effusions confirmed on CXR.
- Although a definite diagnosis can only be made by demonstrating the organisms on smear or culture, or on histology of a pleural biopsy, the presence of a lymphocytic exudate on pleural fluid analysis is adequate to start empiric TB therapy in areas with a high TB burden, particularly if the patient has HIV infection.
- All patients started on empiric TB therapy for pleural TB must be followed up closely; failure to respond as expected must prompt investigations to exclude other causes. Once TB therapy is started, signs and symptoms should resolve within 2 weeks. Radiographic improvement is usually evident by 6 weeks, but complete resorption can take up to 4 months. However, pleural thickening may persist. A pleural biopsy at initial presentation is strongly recommended for the following patients: >50 years of age, suspected malignancy, or those with atypical TB symptoms.
- Treatment is as for pulmonary TB (see Tuberculosis, pulmonary).
Note
Total drainage by aspiration or under-water tube is not needed. For large effusions that cause dyspnoea, drain a maximum of 1 litre at a time. However, note that a TB pleural empyema must be drained by intercostal tube.
REFERRAL
- Non-resolving effusions. Suspect an incorrect diagnosis of TB pleurisy if the effusion does not improve on the CXR after 3 months of treatment, or if the patient deteriorates.
- Loculated TB empyema, not resolving after intercostal underwater tube drainage and needing assessment for surgical drainage.
- Bronchopleural fistula, not resolving after 6 weeks.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024
Chapter 16: Respiratory Disorders _16.10 Tuberculosis, Pleural (TB Pleurisy)