study country with high rate of immigrant population: Aretrospective Epidemiology and diagnosis of pleural tuberculosis in a lowincidence International Journal of Infectious Diseases

Epidemiology and diagnosis of pleural tuberculosis in a low incidence country with high rate of immigrant population: A retrospective study

Antonio Macías

, Adrián Sánchez-Montalvá

*, Fernando Salvador

, Ana Villar

, Teresa Tórtola

, Nuria Saborit

, Israel Molina

aInfectiousDiseasesDepartment,Valld’HebronUniversityHospital,PROSICSBarcelona,UniversitatAutònomadeBarcelona,Barcelona,Spain

bGrupodeEstudiodeInfeccionesporMicobacterias,SociedadEspañoladeEnfermedadesInfecciosasyMicrobiologíaClínica,Madrid,Spain

cPneumologyDepartment,Valld’HebronUniversityHospital,UniversitatAutònomadeBarcelona,Barcelona,Spain

dMicrobiologyDepartment,Valld’HebronUniversityHospital,UniversitatAutònomadeBarcelona,Barcelona,Spain

ARTICLE INFO

Articlehistory:

Received3August2018

Receivedinrevisedform6September2018 Accepted8October2018

Corresponding Editor: Eskild Petersen, Aarhus,Denmark

Keywords:

Pleuraltuberculosis Immigrantpopulation Tuberculosisdiagnostictools

ABSTRACT

Background:Theconfirmatorydiagnosisofpleuraltuberculosis(pTB)remainschallenging.Theaimof thisstudywastodescribetheclinicalandepidemiologicalcharacteristicsofpTBpatientsandassessthe yield of differentdiagnostic procedures in a low burden country with ahigh rate of immigrant population.

Methods:AlladultpatientswithpTBbetween2007and2014werestudiedretrospectively.

Results:Onehundredandthreeoutof843patientswithtuberculosishadpTB.Fifty-three(54.1%)were male,andthemedianagewas45years(range18–87years).Fifty-two(50.49%)patientswereimmigrants.

Aconfirmeddiagnosiswasreachedin16patients(15.5%)bymicrobiologicalstudiesofpleuraleffusion.

Lunginvolvementwasdemonstratedbysputumsmearmicroscopyin13/49(26.5%),sputumGeneXpert MTB/RIFtestin13/20(65%),andsputumculturein16/37(43.2%).High-resolutioncomputedtomography (CT)showedlunginvolvementin47.7%ofthepatients.Thecureratewas91.3%atthe1-yearfollow-up.

Threepatientsdied,allofthemwithinthefirstmonthafterdiagnosis.

Conclusions:Thedetectionoflunginvolvementincreasedbytwo-foldwhenlungCTwasused;this correlatedwiththelikelihoodoffindingapositivemicrobiologicalresultonsputumsampletesting.

Pleuralmicrobiologicalstudieshadalowdiagnosticyield,andsputumcouldhaveacomplementaryrole.

©2018TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).

Introduction

Tuberculosis (TB) affects around nine million people and accounts for 1.5 million deaths worldwide every year (World HealthOrganization,2014).IncountrieswithalowincidenceofTB, the epidemiology and clinical presentation of the disease is changing,withanincreasingnumberofcasesofextrapulmonary involvement and a higher proportion of cases in non-native patients (Baussano and Mercadante, 2013). According to the EuropeanUnionStatisticalAgency,3.4millionimmigrantscameto theEuropeanUnion(EU)in2013,andSpainwasinthetopfive

countriesreceivingimmigrants, takinginover280000ofthem (Migrationand migrantpopulationstatistics, 2016).Due tothis persistentflowofimmigrantsandtheincreasingratesexpectedin thecomingyears,TBwillcontinuetobeamajorhealthissueinthe EU(EuropeanCentreforDiseasesPrevention and Control/WHO RegionalOfficeforEurope,2013).

Aftertuberculouslymphadenitis,pleuraltuberculosis(pTB)is themostcommonextrapulmonarypresentationofTBdisease.pTB canappearasacomplicationofaprimarydiseaseorasalong-term effect of dissemination occurring many years after the initial infection (Davies and Pai, 2007). Factors such as age, chronic diseases,andimmunosuppressiveconditionshavebeenassociated withanincreasedincidenceofpleuralinvolvement(Gopietal., 2007).TheincidenceofTBinBarcelonain2015was14.9casesper 100000population,with10%ofpleuralinvolvement(Informea- nual,2015).

*Correspondingauthorat:DepartamentodeEnfermedadesInfecciosas,Hospital UniversitarioValld’Hebron,EdificioGeneral,6^aplanta,PasseigValld’Hebron,119- 129,CP08035,Barcelona,Spain.

E-mailaddress:adsanche@vhebron.net(A.Sánchez-Montalvá).

https://doi.org/10.1016/j.ijid.2018.10.005

1201-9712/©2018TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ContentslistsavailableatScienceDirect

International Journal of Infectious Diseases

j o u r n a lh o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i d

pTBisa problematicdiseaseduetothedifficultyreachinga confirmedbacteriologicaldiagnosis;hencemanytreatmentsare startedbasedonapresumeddiagnosis(Light,2010;Richteretal., 1994).Thepercentageofconfirmeddiagnosisvarieswidely(from 12%to80%)dependingonthestudylocationandprevalenceofthe disease(Porceletal.,2015;Na,2014).Althoughmolecularbiology methodsarebeinggeneralizedforsamplesotherthansputum,the diagnosticyieldofmolecularbiologystudiesonpleuraleffusionis variableandusuallylowerthanthatforsputum(Trajmanetal., 2014;Porceletal.,2013).

Pulmonaryinvolvementin pTB hasbeendescribed inmany series,anditissuggestedtoapproach50%instudiesusinghigh- resolutioncomputedtomography(CT)(Kimetal.,2006).Induced sputumorevenbronchoscopymayincreasetheyieldoftheculture diagnosisofpTB,whichisextremelyusefulinsettingswithahigh burdenofresistancetothefirst-lineanti-TBdrugs(Condeetal., 2003).

The objectiveof this studywas todescribe theclinical and epidemiological characteristics of patients with pTB in a low incidence burden areaand establish the yield of the different microbiologicaltechniques.

Materialsandmethods Studypopulation

This was a retrospective observational study performed at the Vall d’Hebron University Hospital, a tertiary reference centre included in the International Health Program of the Catalan Health Institute (PROSICS), Barcelona, Spain. Patients older than 18years of age with a diagnosis of pTB between January2007andDecember2014wereincluded.Epidemiologi- cal,clinical,andmicrobiologicalinformationwasobtainedfrom all patients through a review of the medical records. The diagnosticapproachandthetreatmentwereatthediscretionof thetreating physician.

Pleuraltuberculosisdefinitions

The diagnosis of pTB was classified as bacteriologically confirmed or probable. Bacteriologically confirmed pTB was defined asapositiveZiehl–Neelsen(ZN)smear,positiveculture, and/orpositivePCRassayfromapleuralsample.ProbablepTBwas consideredifapositiveresponsetoanti-TBdrugswasfoundand one of the following conditions was present: (1) biochemical diagnosis:pleuralexudateswithlymphocytepredominanceand adenosine deaminase (ADA) level higher than 35IU/L; (2) histopathologicalsampleshowingnecrotizinggranulomaand/or caseousnecrosis;(3)pleuraleffusioninapatientwithconfirmed TB atany otherlocation. A positiveresponse totreatmentwas definedassymptomresolutionandpleuraleffusionimprovement by at least 90% of the initial assessment. Pleural biopsy was performedatthediscretionoftheattendingphysician.Themain reasonsforperforminga biopsywerea highriskofmultidrug- resistantTB,highsuspicionofanalternativediagnosis,andapoor clinicalcourse.

Microbiologicalstudies

PleuralsampleswereexaminedmicroscopicallyusingZNstain.

AllsampleswereculturedandincubatedinaBACTECMGIT960 (BectonDickinsonDiagnosticSystems,Baltimore,MD,USA).Drug susceptibilitytestingofMycobacteriumtuberculosiswasdoneusing theBACTECMGIT960SIREKitforthefirst-linedrugs:streptomy- cin,isoniazid,rifampicin,ethambutol,andpyrazinamide(Kentand Kubica,1985).Whenresistancetoanyfirst-linedrugwasdetected,

the drug susceptibility test was broadened to the following antibiotics: amikacin, capreomycin, streptomycin, ethionamide, moxifloxacin,andofloxacin.Molecularbiologytestingwasdone withtheGeneXpertMTB/RIFassay(Cepheid,Sunnyvale,CA,USA) onpleuralsamples.

Imagingassessment

Achest X-raywasperformedforallpatients.Theneedfora high-resolution CT scan was at the discretion of the treating physician. Lung parenchyma findings suggestive of TB, such as nodules, infiltration, cavities, and pleural thickening, were recorded.

Statisticalanalysis

Categoricalvariablesarepresentedastheabsolutenumberand proportion,andcontinuousvariablesareexpressedasthemedian andrange.TheChi-squaretestorFisher’sexacttestwasusedto comparethedistributionofcategoricalvariables,asappropriate, andtheMann–WhitneyU-testorStudentt-testwasusedtoassess continuousvariables(followingevaluationforanormaldistribu- tion through the Kolmogorov–Smirnov test). Results were consideredstatisticallysignificantifthetwo-tailed p-valuewas

<0.05.IBMSPSSStatisticsversion 21.0(IBMCorp., Armonk,NY, USA)wasusedforthestatisticalanalyses.

Ethicalconsiderations

ThestudyprotocolwasapprovedbytheInstitutionalReview BoardofValld’HebronUniversityHospital(Barcelona,Spain).An exemption from obtaining informed consent was granted.

Procedures were performed in accordance with the ethical standardslaiddownin theDeclarationofHelsinkiasrevised in 2012inFortaleza,Brazil(WorldMedicalAssociation,2016).

Results

Of an overall 843 patients with TB, a total of 103 patients fulfilledtheinclusioncriteriaforpTB.Themedianageofthestudy populationwas45years(range18–87years)and51.4%weremale.

Twenty (19.4%) of the patients had an immunosuppressant condition,includingsevenpatientswithanHIV infection.More dataregardingpatientcharacteristicsandepidemiologicalinfor- mationareshowninTable1.Figure1depictsthenumberoftotal TBandpTBcasesperyear.

Regardingsymptoms,thechiefcomplaintswerefever(n=83, 80.5%),pleuriticchest pain(n=70, 67.9%),cough(n=56,54.3%), generalweakness(n=41,39.8%),dyspnoea(n=39,37.8%),diapho- resis (n=37,35.9%),andweightloss(n=33,33.9%).Themedian duration of symptoms was 21days (range 3–365days). Four patients (3.8%) had a personal history of previous TB (two pulmonary TBand two pTB).More clinicaland epidemiological informationisdetailedinTable2.

Whenanalyzingthebiochemicalcharacteristicsofthepleural effusion, 14 of 97 cases (14.4%) did not have a lymphocytic predominanceinpleuraleffusionandfiveof101cases(4.95%)had anADAconcentrationbelowthesuggestedlimittoconsiderthe diagnosis. All of these cases had a confirmed TB diagnosis by cultureorapleuralbiopsyshowinggranulomas.Table3showsthe diagnostic yield accordingto biochemical characteristicsof the pleuraleffusion.

Aconfirmeddiagnosiswasmadein16(15.5%)patients:14by microbiologicalstudiesofpleuraleffusionandsixbymicrobiolog- icalstudiesofpleuralbiopsy,fourofthemwithnegativepleural effusion microbiological studies. The diagnosis for 87 patients

(84.5%) was probableTB. Regardingthe accuracy of diagnostic techniques,theyieldwassuperiorinsputumandpleuralbiopsy samplesthaninpleuraleffusion(Table4).

Twenty-four(23.3%)patientshadlunginvolvementasseenon chestX-ray.High-resolutionCTwasdonefor57(55.34%)patients.

Twenty-sevenoutof57(47.4%)showedlunginvolvementonhigh- resolution CT scan, with 16 patients having any tomographic findingoftuberculouslunginvolvementnotvisualizedintheX- ray, thereby increasing the diagnostic yield of having lung compromiseby2.3times.Moreover,patientswithlungcompro- mise had a higher yield on diagnosis in the sputum sample, comparedwiththosewhodidnothavelungcompromise(72.2%vs.

25%;p=0.002).

Inthedrugsusceptibilitytestassessment,noresistancetoanti- TBdrugswas found.Thirty-nine(37.8%)patientsdevelopedany adverseeffectrelatedtotheanti-TBdrugs.Themostfrequentwere nausea (n=8, 7.7%), mild hepatic cytolysis (n=7, 6.7%), and cholestasis(n=5,4.8%).

The great majority of therapy regimens (96%) included the standard four-drug treatment including isoniazid, rifampicin, pyrazinamide, and ethambutol.Only fourpatientsweretreated withafluoroquinoloneduringfollow-up,withsideeffectsbeing thecauseoftheswitchinallcases.Themediandurationofthe treatmentwas6months(confidenceintervalinterquartilerange 5.5–8.5months).

After1yearoffollow-up,94(91.3%)patientswerecured,five werelost tofollow-up, and fourhad died.Three of the deaths occurredinthehospitalwithinthefirstmonthafterthediagnosis.

In brief, one patient suffered a haemophagocytic syndrome associatedtotheTB,anotherpatienthadmultifactorialencepha- lopathy(age,renalreplacementtherapy,TBinfection,andanti-TB treatment)thatledtodeath,andonecirrhoticpatientdevelopeda fulminant hepato-renal syndrome concomitant with the TB infection.TheremainingpatientdiedofreasonsunrelatedtoTB duringfollow-up.Therewasnocaseofrelapseduringthestudy period.

Figure1.NumberofpleuralTBandtotalcasesofTBatValld’HebronUniversityHospital.Barcelona,Spain2007–2014.

Table1

Demographiccharacteristicsofthepatients(N=103).

Variable Number(%)

Sex(male) 53(51.5%)

Age(years),median(range) 45(18–87)

Foreignborn 52(51.5%)

LatinAmerica 20(38.4%)

Africa 14(26.9%)

Asia 11(21.2%)

EasternEurope 7(13.4%)

DurationofstayinSpainpriortodiagnosis(years),median(range) 3(0–25)

Immunosuppressiveconditions 20(19.4%)

HIVinfection 7(6.7%)

Autoimmunediseases 4(3.9%)

Steroidtherapy 4(3.9%)

Anti-TNFinhibitortherapy 2(1.9%)

Livertransplantation 1(0.9%)

Kidneyreplacementtherapy 1(0.9%)

TNF,tumournecrosisfactor.

Discussion

Inthisstudy,theclinicalandepidemiologicalcharacteristicsof pTB in a tertiary hospital of a low burden country, over eight consecutive years, are described. In Vall d’Hebron University Hospital,pTBaccountsfor12.2%ofthetotalnumberofTBcases.Of note, half of the cohort was foreign-born, mainly from Latin AmericaandAfrica(inconcordancewiththeimmigrantpopula- tioninBarcelona).ThepTBdiagnosiswasmainlybasedonclinical information, biochemical characteristicsof thepleural effusion, and microbiological results obtainedfor another location, with only22(21.3%)havingamicrobiologicalconfirmatoryresultfroma pleuralsample.Sputumsamplesshowedagoodyield,especiallyin patientswithlunginvolvementfoundonimaging.

Fromaclinicalperspective,thesepatientsweremostlyyoung adults,withnoimportantco-morbidpredisposingconditions,and withtheclassicalsignsandsymptomsoffever,pleuriticchestpain, andcough.Thedurationofsymptomsvariedfrom3daysto1year.

Theyield ofbiochemical pleural effusioncharacteristicswas high,withanexudativeeffusionbeingthemostcommonfinding.

Inarecentstudyof548casesperformedbySahnetal.(2013)the diagnosis had 100% specificity if the pleural effusion met the followingcriteria:protein >5g/dl, lymphocytecount>80%, and ADA>45mg/dlIU/L(sensitivityof35%).Inthepatientsincludedin the present study, considering protein>3.5g/dl, lymphocyte

predominance>50%,and ADA>35mg/dl,IU/L the three condi- tionswerepresentin80.2%(77/96cases).

TheyieldofPCRonpleuraleffusionwaslower(sevenpositive casesoutof51,13.7%)thanthatobservedforPCRonsputum(13 positivecasesoutof20,65%).Accordingtootherpublications,the sensitivityoftheGeneXpertassayonpleuraleffusionisusuallylow (around 25%), withhighspecificity (around95%)(Lusibaet al., 2014).Thereasonsforthis arenotclear,but couldprobablybe attributedtothepresenceofPCRinhibitorsinpleuralfluidanda lowbacillaryload(Duetal.,2015).

Regardingpleural biopsy,despitebeingconsideredthemost usefultechniquetoconfirma suspecteddiagnosis,withratesof positivitybetween60%and95%,theindicationforthisinpTBisnot clear (Kirsch et al., 1997). Performing a pleural biopsy is not withoutrisks,althoughdirectinjurytotheadjacentorgans(liver, kidneys,spleen)isveryrare.Theincidenceofpneumothoraxwith aclosedneedleisvariableanddependsontheoperator,butcould bebetween8%and18%(Goudaetal.,2006).Inthepresentstudy, pleuralbiopsywasperformedatthediscretionoftheattending physicianandtheyieldwas64.7%(11/17cases).Theprocedurewas performedin selectedpatients,inwhomthediagnosiswas not reachedwithotherprocedures.Forthisreason,thedifferentyields ofthediagnostictechniquesshouldbeinterpretedwithcaution.

Interestingly, in this study, the sputumyield remainedhigh even in the absence of involvement seen on chest X-ray. In a previous report Conde et al. (2003), found a yield in induced Table2

EpidemiologicalandclinicaldataofpatientswithpleuralTB(2007–2014)^a.

Overall Spanish(n=51) Immigrant(n=52) p-Value

Sex,male 53(51.4%) 26(50.9%) 27(51.9%) 0.92

Age(years) 45(18–87) 46.9(18–87) 34.3(18–77) <0.001

Timetoconsultation(days) 21(3–365) 28(4–365) 20(3–180) 0.31

Extrapleuralinvolvement 31(30%) 25(49%) 24(46.2%) 0.85

HIVco-infection 7(6.7%) 5(9.8%) 2(3.8%) 0.27

Immunosuppression^b 10(9.7%) 6(11.7%) 4(7.6%) 0.52

PositiveTST 45(83.3%) 19(73.1%) 26(96.3%)

Empiricanti-TBtreatment 87(84.4%) 42(82.3%) 45(86.5%) 0.37

ConfirmedpleuralTB 16(15.5%) 9(17.6%) 7(13.5%) 0.55

Pleuralbiopsy 17(16.5%) 10(19.6%) 7(13.4%) 0.28

TB,tuberculosis;TST,tuberculinskintest.

aDataarepresentedasthenumber(percentage)orthemedian(range).

b Immunosuppressionincludesautoimmunediseasesand/orimmunosuppressantagents,corticoidtherapy,biologicaltherapy,andtransplantation.

Table3

Proportionofdiagnosisaccordingtocharacteristicsofthepleuraleffusion.

Samples/methods Total Confirmed Probable p-Value

ADA-positive^ainpleuraleffusion 96/101(95%) 14/16(87.5%) 82/85(96.5%) 0.177

Pleuralexudates 98/100(98%) 15/16(93.8%) 83/84(98.8%) 0.296

Lymphocyticpleuraleffusion 83/97(85.6%) 11/16(68.8%) 72/81(88.9%) 0.052

ADA-positive^a+lymphocyticeffusion+pleuralexudate 77/96(80.2%) 10/16(62.5%) 67/80(83.8%) 0.081 ADA,adenosinedeaminase.

aADA>35IU/IU/L.

Table4

Diagnosticaccuracyofthedifferenttechniquesemployed.

Pleuraleffusion Sputum Pleuralbiopsy

Ziehl–Neelsen Culture PCR Ziehl–Neelsen Culture PCR Anydiagnosticfinding

Total 2/79 10/60 8/52 13/49 16/37 13/20 4/17^a

7/17^b Diagnostic

accuracy

2.5% 16.6% 15.38% 26.5% 43.2% 65% 23.53%^a

41.2%^b

aPositivesmear,positiveculture,orpositivemolecularbiologytest.

b Granulomaorcaseousnecrosis.

sputumof55%inacohortofBrazilianpatientswithpresumptive pTB and no apparent lung involvement on chest X-ray; thus sputuminduction inpatientswithpleural effusionprovides an invaluable opportunity toconfirma probablediagnosis and to performasusceptibilitystudytoguidetreatment.

From ourperspective,weconsideritjustifiedto startanti-TB treatmentinthecaseofanimmigrantfroma highincidenceTB country presenting with a febrile process accompanied by an exudativepleuraleffusionwithahighnumberoflymphocytesanda highADAlevel,unlessthereisahighriskofmultidrug-resistantTBor analternativediagnosisishighlyprobable.Inthissituation,apleural biopsyshouldbeconsidered.In fact, thediagnosiswas probable in87 (84.5%)patientsinthestudycohortandtreatmentwasstartedon thisassumption,leadingtoa100%therapeuticresponse.

Inthestudycohort,theprognosisofthediseasewasfavourable inthemajorityofpatientsandthecureratewas>90%,whichisin concordance with the global plan to end TB (the STOP TB programme)(TheparadigmShift,2015).Thedeathsthatoccurred werenotassociatedwiththepleuralinvolvementitselfandwere related to multi-organ compromise, co-morbid conditions, and immunosuppression.Inotherseries,asinthisstudy,mortalityhas usually been associated with advanced age and co-morbid conditionsnotrelatedtoTB(Efsenetal.,2014).

The limitations of this study include those inherent tothe retrospectivedesign.Itshouldbenotedthattherewasvariability amongphysiciancriteriaandalackofmolecularbiologytestsat thebeginningofthestudyperiod.Moreover,pTBisadiseasethatis challengingtoconfirmwithadifficult-to-establishgoldstandard diagnosis,hinderingtheassessmentofdiagnosticmethods.

In conclusion,pTBrepresents12%ofallTBdiagnosesatVall d’HebronUniversityHospital,withhalfofthecasesdiagnosedin immigrantpatients.Aconfirmeddiagnosiswasachievedin21.3%

ofcasesusingpleuralsamples.Thedetectionoflunginvolvement increasesbytwo-foldwhenlungCTisused,whichcorrelatedwith thelikelihood offindingapositive microbiologicalresultinthe sputumsample.Pleuralmicrobiologicalstudieshadlowdiagnostic yield, and sputum samples, even in the absence of X-ray abnormalities,maysupportthediagnosisandprovideinformation ondrugsusceptibilityofthebacillus.

Consentforpublication Notapplicable.

Availabilityofdataandmaterial

The datasets generated and/or analysed during the current studyarenotpubliclyavailableduetoindividualprivacyreasons, but areavailable from thecorrespondingauthor onreasonable request.

Funding

Theauthorsdeclarethattheyreceivednofundingforthestudy.

Conflictofinterest

Theauthorsdeclarethattheyhavenocompetinginterests.

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