Current Concepts of Tuberculous Pleurisy with Effusion as Derived from Pleural Biopsy Studies

¹ Ward Physician, Veterans Administration Hospital.
² Chief, Tuberculosis Service, Veterans Administration Hospital.

Eleven of 21 patients with the clinical diagnosis of tuberculous pleurisy with effusion showed pleural tissue changes at biopsy characteristic of this disease. It is to be emphasized that these were selected cases in that a diagnostic problem existed at the time of operation. Furthermore, only a 1.5 by 3 cm. piece of parietal pleura was obtained by the operative method used and only a small area was directly observed. The extent and character of the pleural involvement was impressive when considered in relation to prior concepts.

In view of our findings, plus those reported in the recent literature, the natural history of tuberculous pleurisy with effusion might be conceived as beginning with the rupture of a subpleural caseous focus into the pleural space. This occurs frequently, but by no means always, in the post-primary phase. The hypersensitive pleura may or may not respond with the outpouring of an effusion at this time, but in any event, there is extensive invasion of the pleura by the tubercle bacilli leading to sufficient inflammation to produce the large amount of fluid often observed in this entity. The disease may then resolve completely in from 30—60 per cent of cases, lead to invasion of the chest wall, spine, lungs, or blood stream in perhaps 5 per cent of cases, or temporarily resolve and recur within five years in one or both lungs in about 23 per cent, (2) but perhaps as much as 65 per cent (4) of cases. Pleural biopsy, properly done by any method, helps to establish the diagnosis of this potentially grave disease and, equally important, helps to avoid unnecessary treatment and stigma in others.