Approach to patients with suspected tuberculous pleural effusion

ADA: adenosine deaminase; AFB: acid fast bacilli; NAAT: nucleic acid amplification test; TB: tuberculosis.

* Risk factors for TB disease include current or prior history of TB infection or disease, known or possible exposure to a patient with TB disease, and/or past or present residence in or travel to an area where TB is endemic.

¶ Begin empiric 4-drug therapy (usually isoniazid, rifampin, pyrazinamide, and ethambutol). This should be adjusted once drug susceptibility data is available.

Δ The sensitivity of NAAT for pleural fluid or pleural biopsy tissue is low (approximately 40%).

◊ Refer to text for discussion of selecting a biopsy approach.

§ If pleural biopsy is not feasible, empiric antituberculous treatment is reasonable for patients with suspicion for TB based on clinical and epidemiologic data. In such cases, patients should be monitored for clinical improvement. In general, the expected clinical response for patients on appropriate antituberculous therapy is resolution of fever in 2 weeks and resolution of pleural effusion in 6 weeks; if these are not observed, further considerations include drug-resistant TB or alternative diagnosis.