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Tuberculous empyema: Indications / Timing
นพ.ภราดร เจ็ดวรรณะ
ศลัยแพทย์ทรวงอก
โรงพยาบาลสรุาษฏร์ธานี
Introduction
O 5% of patients with TB
develop pleural effusion
O 2nd most common site of extra-pulmonary TB
Pleural tuberculosis
1. Tuberculous pleuritis
2. Tuberculous empyema
3. Late pleural and extra-pleural
complication during of collapse
therapy
4. TB effusion in HIV/AIDS patients
Shield T: General Thoracic surgery 7th edition
Tuberculous and fungal infections of pleura
Tuberculous pleuritis
O During primary TB
O Incidence :5% of Pulmonary TB
O Serofibrinous fluid
O Rupture of subpleural caseous foci into pleural space
Tuberculous pleuritis
O Clinical
O Low–grade fever, weakness, weight loss, night
sweat, nonproductive cough, pleuritis chest pain
O Investigation
O Chest X-ray: pleural effusion ± parenchymal
lesion
O CT scan: assess pleural thickening and fluid
buildup
Tuberculous pleuritis
Tuberculous pleuritis
O Diagnosis
O Pleural fluid
O AFB stain
O Pleural fluid culture
O ADA
O Pleural biopsy
O Concomitant parenchymal disease 1/3 of cases
Tuberculous pleuritis
O Diagnosis
O Pleural fluid positive for M.Tuberculosis
O Pleural biopsy: Tuberculous granuloma,
caseous granuloma
Tuberculous pleuritis
O Spontaneous re-sorption
O Management
O Anti-tuberculous + Close observation
O Drainage
O Decortication
O VATS
Tuberculous pleuritis: Decortication
O Thoracocentasis fails to yield fluid or to alter radiographic appearance.
O Thick pleural peel
O Trapped lung
O Pleural fluid ≥ 1/3 hemithorax
O Timing :
O After 2 to 4 months of drug therapy (Shields: General thoracic surgery 7th ed)
O At least 6 weeks ( Khaled MA. 2000)
Tuberculous pleuritis
Tuberculous empyema
O Pleural reactivation of TB
O Purulent effusion
O Sequelae of pulmonary TB
O Clinical : low-grade fever, dyspnea, ± chest pain
O Abundant sputum – bronchopleural fistula
Tuberculous empyema
O Diagnosis
O Purulent pleural fluid
O AFB stain and gram stain or
culture
O Chest X-ray
O Air-fluid level suggest bronchopleural fistula
Tuberculous empyema
O Management
O Adequate drainage
O Chest drain
O Open pleural window
O Convert sputum cultures with medical treatment
before resection
O Definitive treatment
Definitive treatment
O Decortication
O Lung parenchymal resection
O Extra-pleura pneumonectomy
O Open window thoracostomy
Decortication
O symptomatic extra-parenchymal restrictive disease secondary to fibrothorax
O thoracentesis, tube drainage, or thoracoscopy have failed to drain the pleural space and expand the lung
O Indication O The pleural peel has been present for more than 4-
6 weeks
O Lung symptoms are disabling
O There is radiological evidence of a trapped lung
Additional parenchymal resection
O MDR-TB
O Hemoptysis
O Aspergilloma
O Cystic bronchiectasis/infection
Avoid pneumonectomy whenever possible
Extra-pleura pneumonectomy
O Symptomatic severe destroyed lung
O Bronchopleural fistula
O Hemoptysis
Appropriate timing of surgical intervention
O After 2 to 4 months of drug therapy (Shields: General thoracic surgery 7th ed)
O At least 6 weeks ( Khaled MA. 2000)
Definitive treatment
1) Is underlying lung expandable ?
2) Is parenchymal resection required ?
3) Is the patient high risk for surgery ?
Treatment plan for chronic mycobacterial empyema
Treatment plan for chronic mycobacterial empyema
Chronic Tuberculous Empyema
Pleural calcification
Post-op problem after decortication
O Pleural space problem
O Prolong air leak
Pleural space problem
O Muscle flap
O Plombage
O Thoracoplasty
O Open pleural window
Open pleural window
References
O Shield T: General Thoracic surgery 7
edition
O Khaled MA. Management of tuberculous
empyema.Eur J Thorac Surg 17 (2000) 251-254
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