Aula ministrada pelo Prof. Dr Angelo Casalini no dia 09/05/12 no I Simpósio Brasil-Itália, sediado no Hospital Universitário João de Barros Barreto (UFPA - Belém).
7. • 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
U.O. di Pneumologia - Endoscopia Toracica
8. GOLD STANDARD
1. Isolamento do BK
a) Líquido pleurico
b) Escarro ou broncoaspirado
c) Biópsia
2. Exame histológico
a) Biópsia transcutânea
b) Biópsia toracoscópica
U.O. di Pneumologia - Endoscopia Toracica
9. 2 Radiologia:
•útil só se lesões pulm.
típicas associadas
70 pacientes
4.9% di 1738 casos de tbc
35 lesões 35 não lesões
parenquimatosas parenquimatosas
escarro + 31/35 escarro + 4/35
(89%) (11%)
Seilbert AF. Tuberculous pleural effusions: Twenty year experience.
Chest 1991; 99:883. U.O. di Pneumologia - Endoscopia Toracica
11. AFB smear Culture of
M. Tb
No parenchymal 11% (7/64) 54% (35/64)
lesions (64 Pts)
With parenchymal 15% (3/20) 45% (9/20)
lesions (20 Pts)
Cerca de50% dos pacientes com pleurite TBC eliminam BK com escarro:
epidemiológicamente relevante!!!
U.O. di Pneumologia - Endoscopia Toracica
14. 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.
U.O. di Pneumologia - Endoscopia Toracica
18. TPE = tuberculous pleural effusion
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.
U.O. di Pneumologia - Endoscopia Toracica
22. •Tuberculous pleuritis is a treatable cause of a lymphocytic pleural
effusion.
•It is desirable to exclude the diagnosis in patients with lymphocytic
N.B. 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.
U.O. di Pneumologia - Endoscopia Toracica
23. • 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
U.O. di Pneumologia - Endoscopia Toracica
dati personali non pubblicati
25. 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 6/13 = 46%
2 PCR (biópsia e fibrina)
*nos 2 pacientes que fizeram a toraco a cultura da biópsia foi negativa
** Realizado Toraco em 13/16 pacientes
U.O. di Pneumologia - Endoscopia Toracica
26. direto cultura
Líquido 3 PCR 2/24 = 8,3%
pleurico
Escarro nunca
FBS Nunca (não
realizado ou
negativo)
Toraco* (23) 1 Direto 14/23 = 60%
3 PCR (biópsia e fibrina)
*Realizaado toraco em 23/24 pacientes
U.O. di Pneumologia - Endoscopia Toracica
27. 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
28. Riscos por falta de diagnóstico de uma pleurite
tubercular
35%: cura espontânea
92/141 (65%): desenvolvem TBC
pulmonar ou extrapulmonar em 5 anos
Indispensável o diagnóstico de certeza
Para iniciar um tratamento correto
WH Roper, JJ Waring. Primary serofibribous pleural effusion in military personel. Am Rev Tuberc
Pulm Dis 1955; 71:616-634. U.O. di Pneumologia - Endoscopia Toracica
29. Tuberculous pleural Therapy Resolution
effusions time
No therapy 2-4 mo
INH, rifampin 2 mo
INH, rifampin,PZA 1-2 mo
Addition of prednisone 1-2 mo
U.O. di Pneumologia - Endoscopia Toracica
30. 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.
31. 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
U.O. di Pneumologia - Endoscopia Toracica
Editor's Notes
113 pazienti elegibili 84 diagnosi finale di pleurite tubercolare (criteri diagnostici: presenza del BK o diagnosi istologica di flogosi granulomatosa o presuntiva (dopo 3 mesi di terapia)