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Suggest Treatment When Chest X Ray Shows Pleural Effusion
Question: hello doc,
recently a person diagnosed with decompensated alcoholic liver disease with ascites with early encephalopathy with DM was admitted in a government hospital for hemetemesis and malena,but on further investigation xray chest revealed pleural effusion also.ascetic and pleural tap was done and sample sent for ADA test and was started on non dots traatment with diagnosis been written as pleural tb.the said person was discharged from the govt. hospital admitted in a private hospital wherein a repeat ascetic tap was done only and since the report was normal the anti TB treatment was stopped.,even though the patient still gets spikes of 100°F. I would just like to know whether the decision was correct or wrong and secondly can a ADA test of ascetic fluid determine the absence of tb in the pleural fluid.
recently a person diagnosed with decompensated alcoholic liver disease with ascites with early encephalopathy with DM was admitted in a government hospital for hemetemesis and malena,but on further investigation xray chest revealed pleural effusion also.ascetic and pleural tap was done and sample sent for ADA test and was started on non dots traatment with diagnosis been written as pleural tb.the said person was discharged from the govt. hospital admitted in a private hospital wherein a repeat ascetic tap was done only and since the report was normal the anti TB treatment was stopped.,even though the patient still gets spikes of 100°F. I would just like to know whether the decision was correct or wrong and secondly can a ADA test of ascetic fluid determine the absence of tb in the pleural fluid.
Brief Answer:
Treat for TB only if results are positive
Detailed Answer:
Hi XXXX
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
1. It is a usual practice in Government hospitals to start treatment of any pleural effusion as TB after preliminary testing. In your case it is not clear if ascitic and pleural fluid were sent for ADA test or only one of the samples. If ascitic fluid is positive then diagnosis of abdominal TB should have been written and if pleural fluid was positive then pleural TB. If both were positive then you have to write both. Treatment with dots is only after test is positive.
2. If repeat testing revealed normal ADA in ascitic tap and pleural tap then she may not have TB. As patient is having DM therefore other infections can always cause spiking of fever and in such case the focus of infection needs treatment.
3. Hematemesis, melena, ascites and pleural effusion can be explained by decompensated alcoholic liver disease.
4. In reply to your query, it is correct to stop treatment of TB if there is not enough evidence of disease.
2. ADA test can be done with both ascitic and pleural fluid and the result indicates presence of TB in the region concerned. You cannot diagnose pleural TB from ascitic fluid. The pleural cavity is separated from abdomen.
Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.
Hope your query is answered.
Do write back if you have any doubts.
Regards,
Dr.Vivek
Treat for TB only if results are positive
Detailed Answer:
Hi XXXX
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
1. It is a usual practice in Government hospitals to start treatment of any pleural effusion as TB after preliminary testing. In your case it is not clear if ascitic and pleural fluid were sent for ADA test or only one of the samples. If ascitic fluid is positive then diagnosis of abdominal TB should have been written and if pleural fluid was positive then pleural TB. If both were positive then you have to write both. Treatment with dots is only after test is positive.
2. If repeat testing revealed normal ADA in ascitic tap and pleural tap then she may not have TB. As patient is having DM therefore other infections can always cause spiking of fever and in such case the focus of infection needs treatment.
3. Hematemesis, melena, ascites and pleural effusion can be explained by decompensated alcoholic liver disease.
4. In reply to your query, it is correct to stop treatment of TB if there is not enough evidence of disease.
2. ADA test can be done with both ascitic and pleural fluid and the result indicates presence of TB in the region concerned. You cannot diagnose pleural TB from ascitic fluid. The pleural cavity is separated from abdomen.
Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.
Hope your query is answered.
Do write back if you have any doubts.
Regards,
Dr.Vivek
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Actually pleural and ascetic fluids were sent for ADA test,wherein only pleural fluid was diagnosed as positive whereas ascetic fluid was negative.,this was in the govt .hospital where non dots was started. In private hospital only ascitic fluid was sent for ADA test and as it came negative ,the doctors stopped the anti-kochs treatment,hence I assume that since pleura and peritoneum are 2 different regions of the body without any connection the stoppage of treatment was wrong. What is your opinion doc?
Brief Answer:
Treatment of TB should not be stopped
Detailed Answer:
Hi,
Thanks for writing back with an update.
Please find my observations below.
As per medical literature
1. Elevated ADA activity in PF is a sensitive and specific marker for the diagnosis of tuberculous pleuritis, particularly in high prevalence areas, with reported sensitivity of 92% and specificity of 90% at a generally accepted cut-off point of 40 U/L. Therefore pleural ADA if positive usually indicates TB.
2. However, ADA was only 30% sensitive in detecting tuberculous peritonitis in the setting of cirrhosis, in a study done in United States and cirrhosis was present in 59% of the tuberculous peritonitis patients.
3. As above patient had alcoholic liver disease, ADA negative in ascitic fluid does not mean she does not have disease as there is confirmation of TB in pleural fluid.
4. They should not have stopped treating for TB in my opinion.
Hope your query is answered.
Do write back if you have any doubts.
Regards,
Dr.Vivek
Treatment of TB should not be stopped
Detailed Answer:
Hi,
Thanks for writing back with an update.
Please find my observations below.
As per medical literature
1. Elevated ADA activity in PF is a sensitive and specific marker for the diagnosis of tuberculous pleuritis, particularly in high prevalence areas, with reported sensitivity of 92% and specificity of 90% at a generally accepted cut-off point of 40 U/L. Therefore pleural ADA if positive usually indicates TB.
2. However, ADA was only 30% sensitive in detecting tuberculous peritonitis in the setting of cirrhosis, in a study done in United States and cirrhosis was present in 59% of the tuberculous peritonitis patients.
3. As above patient had alcoholic liver disease, ADA negative in ascitic fluid does not mean she does not have disease as there is confirmation of TB in pleural fluid.
4. They should not have stopped treating for TB in my opinion.
Hope your query is answered.
Do write back if you have any doubts.
Regards,
Dr.Vivek
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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