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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 854-855
Vesicular pleuritis in a case of tuberculous empyema thoracis


1 Department of Pathology, CSM Medical University, Lucknow, India
2 Department of Cardiothoracic Surgery, CSM Medical University, Lucknow, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Husain N, Kumari M, Tandon S. Vesicular pleuritis in a case of tuberculous empyema thoracis. Indian J Pathol Microbiol 2010;53:854-5

How to cite this URL:
Husain N, Kumari M, Tandon S. Vesicular pleuritis in a case of tuberculous empyema thoracis. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 6];53:854-5. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/854/71999


Sir,

Tuberculous pleuritis classically presents with fibrinous pleuritis with or without a granulomatous inflammation. Suppurative infection has also been described. [1],[2] Vesicular lesions in pleura have not been reported in literature. We report an interesting case of vesicular tubercular pleuritis in a 17-year-old male who presented with recurrent fever, dyspnoea, cough with expectoration and loss of appetite since six months. There was no history of smoking, alcohol, hypertension or diabetes mellitus. The patient was HIV-negative and not immuno-compromised. Clinical examination revealed absence of breath sounds on the left side of the thorax. Computed tomography (CT) Scan of the thorax showed consolidation with fibrinous infiltrates in left lower lobe along with a loculated pyothorax. Pleural thoracotomy was done. A large quanity of pus was aspirated from the pleural cavity. Pleural de-cortication was done with removal of adherent thickened parietal and visceral pleura. After the thoracotomy and pleural excision, the lung re-expanded. Chest was closed over a left inter costal drainage.

On gross examination, pleura was markedly thickened and edematous, outer surface was smooth and visceral surface was nodular with contiguous sheets of vesicles [Figure 1]a. Histology revealed visceral pleural surface marked by a contiguous line of blebs filled with clear fluid with surrounding dispersed mixed inflammatory exudate and no epithelial lining. Underlying tissue showed fibrosis with intense mixed inflammatory infiltrates comprising of lymphocytes, plasma cells, neutrophils and macrophages [Figure 1]b. No specific granuloma was evident and Ziehl-Neelsen staining for Mycobacterium tuberculosis, Gomori methinamine silver (GMS) for fungi and Gram's staining were negative.
Figure 1: a: Pleural decortication specimen shows contiguous sheets of vesicles on the visceral surface
b: Photomicrograph shows blebs with no lining, filled with clear fluid, (arrow) and fibrinous exudates (dotted arrow) (H and E, x 50)


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Biochemical analysis of pleural fluid showed increased lactate dehydrogenase (270 U/ml), low glucose (46 mg/dl) and high protein (2.9 gm /dL). Microscopic examination showed increase cell count predominantly lymphocytes. Polymerase chain reaction (PCR) for mycobacterial DNA in pleural fluid was positive for Mycobacterium tuberculosis (IS6110 fragment). Aerobic bacterial culture and Gram's staining was negative in pleural fluid. Patient was considered a case of tuberculous empyema thoracis and anti-tubercular treatment was started with a four-drug regime. Patient responded well to therapy.

Bleb-like lesions below the visceral pleura surrounded by relatively loose fibrotic tissue have been observed in a case of recurrent spontaneous pneumothorax associated with juvenile polymyositis reported by Sato et al. [3] Masaki M et al.[4] observed vesicular lesions in the skin along with pleural effusion caused by Varicella zoster virus in a case of acute lymphatic leukaemia. Pleural fluid smears in this case showed numerous mesothelial cells with ground glass nuclei (nuclear inclusion) and multinucleated giant cells. In an extensive review of literature, we have not come across any description of vesicular pleuritis in tuberculosis. High pleural fluid adenosine deaminase (ADA) level of >50.0 U/l or positive polymerase chain reaction for Mycobacterium tuberculosis, combined with Lymphocyte/Neutrophil ratio ≥ 0.75 is a good diagnostic tool for tubercular pleuritis. [5] The current communication is intended to present this unusual picture of tubercular pleuritis.

 
   References Top

1.Antoniskis D, Amin K, Barnes PF. Pleuritis as a manifestation of reactivation tuberculosis. Am J Med 1990;89:447-50.  Back to cited text no. 1
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2.Malhotra P, Aggarwal A, Agarwal R, Ray P, Gupta D, Jindal S. Clinical characteristics and outcomes of empyema thoracis in 117 patients: A comparative analysis of tuberculous vs. non-tuberculous aetiologies. Resp Med 2007;101 423-30.  Back to cited text no. 2
    
3.Sato M, Bando T, Hasegawa S, Kitaichi M, Wada H. Recurrent spontaneous pneumothoraces associated with juvenile polymyositis. Chest 2000;118:1509-11.  Back to cited text no. 3
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4.Masaki M, Yoshiaki I, Hideki M, Haruyoshi Y, Hironobu N, Masaru F. Cytology of pleural effusion associated with disseminated infection caused by varicella zoster virus in an immunocompromised patient: A case report. Acta Cytol 2003;47:480-4.   Back to cited text no. 4
    
5.Diacon AH, Van de Wal BW, Wyser C, Smedema JP, Bezuidenhout J, Bolliger CT, et al. Diagnostic tools in tuberculous pleurisy: A direct comparative study. Eur Respir J 2003;22:589-91.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Nuzhat Husain
Department of Pathology, CSM (Erstwhile King George's) Medical University, Lucknow - 226 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.71999

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