OBJECTIVES: Tuberculosis is one of the most prevalent infections in humans. Although culture is the reference for diagnosis, its sensitivity is compromised, especially in paucibacillary samples. Because polymerase chain reaction (PCR) amplifies mycobacterial DNA, it is more sensitive than culture for the diagnosis of Mycobacterium tuberculosis (Mtb). However, its performance can be affected by intrinsic sample inhibitors and by the extraction/detection techniques used. METHODS: We evaluated the influence of preanalytical conditions on Mtb detection in samples of sputum (SPU), bronchoalveolar lavage (BAL), and pleural fluid (PF) using combinations of extraction/detection methods. Respiratory samples were prepared to contain different concentrations of red blood cells and nucleated cells to which increasing amounts of Mtb colonies were inoculated and submitted to PCR. RESULTS: Up to 102 CFU/ml of Mtb were detected in the SPU in all methods, except for the Roche extraction/detection method, regardless of the preanalytical sample condition. In BAL samples, medium and high concentrations of cells and high concentrations of red blood cells contributed to a lower Mtb detection, regardless of the extraction method used. In PF, red blood cells were the variable that most interfered with Mtb detection, with better recovery (102 CFU/ml) observed with the Qiagen/Nanogen combination. CONCLUSION: The choice of Mtb extraction and detection method is of fundamental importance for PCR analytical sensitivity, especially when paucibacillary samples and/or samples containing potential PCR inhibitors are analyzed.

OBJETIVO: Descrever características clínicas e laboratoriais em pacientes com derrames pleurais linfocíticos secundários a tuberculose ou linfoma, a fim de identificar as variáveis que possam contribuir no diagnóstico diferencial dessas doenças. MÉTODOS: Estudo retrospectivo com 159 pacientes adultos HIV negativos com derrame pleural linfocítico secundário a tuberculose ou linfoma (130 e 29 pacientes, respectivamente) tratados no Ambulatório da Pleura, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP), entre outubro de 2008 e março de 2010. RESULTADOS: A média de idade e de duração dos sintomas foi menor no grupo tuberculose que no grupo linfoma. Os níveis pleurais de proteínas, albumina, colesterol, amilase e adenosina desaminase (ADA), assim como os níveis séricos de proteínas, albumina e amilase, foram maiores no grupo tuberculose, enquanto os níveis séricos de colesterol e triglicérides foram maiores no grupo linfoma. As contagens de leucócitos e linfócitos no líquido pleural foram maiores no grupo tuberculose. Células malignas estavam ausentes no grupo tuberculose, entretanto, linfócitos atípicos foram observados em 4 desses pacientes. No grupo linfoma, a citologia para células neoplásicas foi positiva, suspeita e negativa em 51,8%, 24,1% e 24,1% dos pacientes, respectivamente. A imunofenotipagem do líquido pleural foi conclusiva na maioria dos pacientes com linfoma. CONCLUSÕES: Nossos resultados demonstram semelhanças clínicas e laboratoriais entre os pacientes com tuberculose ou linfoma. Embora os níveis de proteínas e ADA no líquido pleural tendam a ser mais elevados no grupo tuberculose que no grupo linfoma, mesmo essas variáveis mostraram uma sobreposição. Entretanto, nenhum paciente com tuberculose apresentou níveis de ADA no líquido pleural inferiores ao ponto de corte (40 U/L).

OBJECTIVE: To describe clinical and laboratory characteristics in patients with tuberculosis-related or lymphoma-related lymphocytic pleural effusions, in order to identify the variables that might contribute to differentiating between these diseases. METHODS: This was a retrospective study involving 159 adult HIV-negative patients with tuberculosis-related or lymphoma-related lymphocytic effusions (130 and 29 patients, respectively), treated between October of 2008 and March of 2010 at the Pleural Diseases Outpatient Clinic of the University of São Paulo School of Medicine Hospital das Clínicas Heart Institute, in the city of São Paulo, Brazil. RESULTS: Mean age and the mean duration of symptoms were lower in the tuberculosis group than in the lymphoma group. The levels of proteins, albumin, cholesterol, amylase, and adenosine deaminase (ADA) in pleural fluid, as well as the serum levels of proteins, albumin, and amylase, were higher in the tuberculosis group, whereas serum cholesterol and triglycerides were higher in the lymphoma group. Pleural fluid leukocyte and lymphocyte counts were higher in the tuberculosis group. Of the tuberculosis group patients, none showed malignant cells; however, 4 showed atypical lymphocytes. Among the lymphoma group patients, cytology for neoplastic cells was positive, suspicious, and negative in 51.8%, 24.1%, and 24.1%, respectively. Immunophenotyping of pleural fluid was conclusive in most of the lymphoma patients. CONCLUSIONS: Our results demonstrate clinical and laboratory similarities among the patients with tuberculosis or lymphoma. Although protein and ADA levels in pleural fluid tended to be higher in the tuberculosis group than in the lymphoma group, even these variables showed an overlap. However, none of the tuberculosis group patients had pleural fluid ADA levels below the 40-U/L cut-off point.

OBJECTIVES: To evaluate the effectiveness and safety of pleurodesis carried out entirely on an outpatient basis in patients with recurrent malignant pleural effusions and Karnofsky Performance Status scores <70. METHODS: This study was a prospective trial comprising patients with symptomatic recurrent malignant pleural effusion and Karnofsky Performance Status scores <70 but >30. All selected patients underwent pleural catheter placement (14 Fr) in an outpatient facility. When chest radiography revealed post-drainage lung expansion of >90%, pleurodesis (3 g of talc) was performed. Catheters were maintained until the daily output was ,100 mL/day. The patients were evaluated in the first month and every three months thereafter for fluid recurrence, the need for additional procedures, and complications. RESULTS: During the study period (January 2005 to July 2007), 64 patients (24 men, 40 women), with an average age of 61.4 years, underwent elective chest tube drainage. Primary sites of the underlying malignancy were breast (27), lung (22), and others (15). Sixty-six pleural catheters were placed (bilaterally in 2 patients), and 52 talc pleurodesis procedures were performed. Fourteen patients had a trapped lung and were excluded from the trial. No complications were observed during catheter placement or pleurodesis. Post-pleurodesis complications included catheter obstruction (4 patients) and empyema (1). The average drainage time was 9.9 days. The recurrence rate observed in patients that were alive 30 days after pleurodesis was 13.9% (5/36 patients). Six patients required additional procedures after the pleurodesis. The average survival time was 101 days. CONCLUSION: In this study, talc pleurodesis was safely performed in an outpatient setting with good efficacy and a reasonable complication rate, thereby avoiding hospital admission.

OBJETIVO: A pleurodese é uma alternativa eficaz no controle dos derrames pleurais malignos, mas existem controvérsias a respeito de sua indicação e técnica. O objetivo deste estudo foi avaliar como é realizada a pleurodese em países da América do Sul e Central. MÉTODOS: Profissionais que realizam pleurodese responderam um questionário sobre critérios de indicação para pleurodese, técnicas utilizadas e desfechos. RESULTADOS: Nossa amostra envolveu 147 profissionais no Brasil, 49 em outros países da América do Sul e 36 em países da América Central. Mais de 50% dos participantes realizavam pleurodese somente se confirmada a malignidade no derrame pleural. Entretanto, escalas de dispneia e de status de performance eram raramente utilizadas para indicar o procedimento. Aproximadamente 75% dos participantes no Brasil e na América Central preferiam realizar a pleurodese somente no caso de recidiva do derrame, e a expansão pulmonar deveria variar de 90% a 100%. O talco slurry foi o agente mais utilizado, instilado via drenos de calibre intermediário. A toracoscopia foi realizada em menos de 25% dos casos. Febre e dor torácica foram os efeitos adversos mais comuns, e empiema ocorreu em < 14% dos casos. A média de sobrevida após o procedimento variou entre 6 e 12 meses. CONCLUSÕES: Há variações consideráveis quanto aos critérios de indicação para pleurodese, técnicas utilizadas e desfechos entre os países. Talco slurry é o agente mais frequentemente utilizado, e a toracoscopia é a primeira escolha no Brasil. Os baixos índices de complicações e o tempo de sobrevida elevado indicam que a pleurodese é efetiva e causa poucos efeitos adversos.

OBJECTIVE: Pleurodesis is an effective alternative for the control of malignant pleural effusions. However, there is as yet no consensus regarding the indications for the procedure and the techniques employed therein. The objective of this study was to evaluate how pleurodesis is performed in South and Central America. METHODS: Professionals who perform pleurodesis completed a questionnaire regarding the indications for the procedure, the techniques used therein, and the outcomes obtained. RESULTS: Our sample comprised 147 respondents in Brazil, 49 in other South American countries, and 36 in Central America. More than 50% of the respondents reported performing pleurodesis only if pleural malignancy had been confirmed. However, scores on dyspnea and performance status scales were rarely used as indications for the procedure. Nearly 75% of the respondents in Brazil and in Central America preferred to perform pleurodesis only for recurrent effusions and stated that lung expansion should be 90-100%. Talc slurry, instilled via medium-sized chest tubes, was the agent most often employed. Thoracoscopy was performed in less than 25% of cases. Fever and chest pain were the most common side effects, and empyema occurred in < 14% of cases. The mean survival time after the procedure was most often reported to be 6-12 months. CONCLUSIONS: There was considerable variation among the countries evaluated in terms of the indications for pleurodesis, techniques used, and outcomes. Talc slurry is the agent most commonly used, and thoracoscopy is the technique of choice in Brazil. Pleurodesis is an effective procedure that has few side effects, as evidenced by the low complication rates and high survival times.

OBJETIVO: Analisar as características epidemiológicas e tendências quanto à incidência de TB pleural. MÉTODOS: Estudo descritivo, retrospectivo dos casos de TB reportados entre 1998 e 2005 e coletados do banco de dados do Sistema de Notificação de Tuberculose (Epi-TB) da Secretaria de Saúde do Estado de São Paulo. RESULTADOS: Foram notificados 144.347 casos novos de TB durante o período estudado. A forma pulmonar foi predominante (118.575 casos; 82,2%). Das formas extrapulmonares (25.773 casos; 17,8%), a pleural foi a mais referida (12.545 casos; 48,7%). A incidência (por 100.000 habitantes) de todas as formas diminuiu, (49,7 em 1998 e 44,6 em 2005; R² = 0,898; p < 0,001), enquanto a incidência de TB pleural permaneceu estável (4,1 em 1998 e 3,8 em 2005; R² = 0,433; p = 0,076). A maior incidência de TB pleural ocorreu em pacientes do sexo masculino (2:1) entre 30 e 59 anos de idade. Dos 12.545 pacientes com TB pleural, 4.018 (32,0%) apresentaram comorbidades: alcoolismo (9,5%); HIV (8,0%); diabetes (3,3%); e doença mental (1,2%). O diagnóstico referido fundamentou-se em métodos bacteriológicos (14,2%) e histológicos (30,2%), assim como outros não especificados (55,6%). CONCLUSÕES: No estado de São Paulo, a TB pleural foi a forma extrapulmonar predominante, apresentando incidência estável no período entre 1998 e 2005, apesar da tendência de diminuição das formas pulmonares. A histologia e a bacteriologia definiram o diagnóstico em 44,4% dos casos.

OBJECTIVE: To analyze the epidemiological characteristics of and trends regarding the incidence of pleural TB. METHODS: This was a retrospective descriptive study of TB cases reported between 1998 and 2005 and compiled from the Epidemiological Surveillance Tuberculosis System (Epi-TB database). RESULTS: A total of 144,347 new cases of TB were reported during the period studied. Pulmonary TB was the predominant form (118,575 cases; 82.2%). Among the extrapulmonary forms (25,773 cases; 17.8%), pleural TB was the form most often reported (12,545 cases; 48.7%). For all forms, the incidence (per 100,000 population) decreased (from 49.7 in 1998 to 44.6 in 2005; R² = 0.898; p < 0.001), whereas the incidence of pleural TB remained stable (4.1 in 1998 and 3.8 in 2005; R² = 0.433; p = 0.076). The highest incidence of pleural TB was found among males (2:1) aged from 30 to 59 years. Of the 12,545 patients with pleural TB, 4,018 (32.0%) presented comorbidities: alcoholism (9.5%); HIV (8.0%); diabetes (3.3%); and mental illness (1.2%). The diagnosis was based on bacteriological (14.2%) and histological (30.2%) methods, as well as on unspecified methods (55.6%). CONCLUSIONS: Pleural TB was the predominant extrapulmonary form of TB in the state of São Paulo, with a stable incidence between 1998 and 2005, although there was a trend toward a decrease in the incidence of the pulmonary forms. The diagnosis of pleural TB was confirmed through histology and bacteriology in 44.4% of the cases.

OBJECTIVE: The aim of this study was to identify the participation of the coagulation system in the differential diagnosis of pleural effusions. INTRODUCTION: Imbalance between immunologic and metabolic factors triggers a sequence of events resulting in pleural reactions and accumulation of fluid. The coagulation system, which is fundamental for the maintenance of homeostasis, contributes to the inflammatory process responsible for pleural effusions, and participates in cellular proliferation and migration as well as in the synthesis of inflammatory mediators. METHODS: We evaluated the laboratory profile of coagulation and fibrinolysis in 54 pleural fluids (15 transudates and 39 exudates). RESULTS: The coagulation system acts according to the pathophysiologic mechanisms involved in the development of pleural effusions. In inflammatory effusions (exudates), there is activation of coagulation with increased levels of fragment 1+2 and thrombin-antithrombin complex in addition to reduction of fibrinogen levels due to fibrinolysis and fibrin tissue incorporation. As a consequence, there is activation of the fibrinolytic system with increased levels of fibrin degradation products, including the D-dimer. These changes are not sufficient for differentiation of different subgroups of exudates. In transudates, these events were observed to a lesser degree. CONCLUSION: The coagulation system plays an important role in the development of pleural diseases. Coagulation tests show differences between transudates and exudates but not among exudate subgroups. Understanding the physiopathological mechanisms of pleural disorders may help to define new diagnostic and therapeutic approaches.

OBJETIVOS: Avaliar a experiência com o diagnóstico e a terapêutica do mesotelioma pleural maligno (MPM) acumulada durante 5 anos em um hospital público terciário. MÉTODOS: Avaliação retrospectiva dos prontuários dos pacientes com diagnóstico de MPM entre janeiro de 2000 e fevereiro de 2005. RESULTADOS: Foram analisados 17 pacientes, 14 homens e 3 mulheres, com idade média de 54,1 (13-75) anos. Os espécimes de biópsia para exame histopatológico foram obtidos por meio de pleuroscopia em 9 pacientes (53%), agulha de Cope em 5 (29,5%) e biópsia pleural aberta em 3 (17,5%). Os tipos histológicos foram: epitelial em 14 pacientes (82%), sarcomatóide em 1 (6%) e bifásico em 2 (12%). As terapêuticas instituídas foram: multimodal (pleuropneumonectomia com radioterapia e quimioterapia adjuvante) em 6 pacientes (35%), quimioterapia e radioterapia em 6 (35%), radioterapia exclusiva em 3 (17,5%) e quimioterapia exclusiva em 2 (12%). A sobrevida média foi de 11 (1-26) meses. CONCLUSÕES: Na presente experiência foi empregada a abordagem multidisciplinar integrada, e contou-se com uma estrutura hospitalar de alta complexidade para o diagnóstico e tratamento do MPM, como preconizado na literatura. Apesar disso, a sobrevida média observada foi de apenas 11 meses, refletindo a agressividade da doença.

OBJECTIVE: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. METHODS: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. RESULTS: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53%), Cope needle in 5 (29.5%), and open pleural biopsy in 3 (17.5%). The following histological types were identified: epithelial, in 14 patients (82%); sarcomatoid, in 1 (6%); and biphasic, in 2 (12%). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35%); chemotherapy and radiotherapy in 6 (35%); radiotherapy alone in 3 (17.5%); and chemotherapy alone in 2 (12%). The mean survival was 11 months (range, 1-26 months). CONCLUSIONS: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

OBJETIVO: Avaliar as características clínicas e laboratoriais de derrames pleurais secundários à tuberculose ou câncer. MÉTODOS: Um total de 326 pacientes com derrame pleural por tuberculose (n=182) ou câncer (n=144) foi avaliado. Os seguintes parâmetros foram analisados: sexo e idade dos pacientes e características do líquido pleural (tamanho, localização, aspecto macroscópico, concentração de proteínas, atividade da desidrogenase lática (DHL) e da adenosina deaminase (ADA) e contagem de células nucleadas). RESULTADOS: A tuberculose pleural predominou nos pacientes mais jovens e do sexo masculino. Em ambos os grupos, os derrames pleurais foram de tamanho moderado e unilaterais. Derrames com aspecto amarelo-citrino com níveis mais elevados de proteínas predominaram na tuberculose (5,3 ± 0,8 g/dL), quando comparados aos neoplásicos (4,2 ± 1,0 g/dL), enquanto que níveis mais elevados de DHL foram observados nos derrames neoplásicos (1.177 ± 675 x 1.030 ± 788 UI; p = 0,003). Conforme esperado, a atividade da ADA foi maior na tuberculose que no câncer (107,6 ± 44,2 x 30,6 ± 57,5 U/L; p < 0,001). Ambos os derrames apresentaram alta celularidade, embora mais pronunciada no grupo neoplásico (p < 0,001). Os derrames de etiologia tuberculosa se caracterizaram por apresentar uma maior percentagem de leucócitos e de linfócitos (p < 0,001) e um pequeno número de células mesoteliais (p = 0,005). Linfócitos e macrófagos foram as células nucleadas que predominaram nos derrames pleurais malignos. CONCLUSÃO: Nossos resultados demonstram que em exsudatos pleurais linfocíticos de pacientes com evidências clínicas e radiológicas de tuberculose, os níveis de proteína e de ADA foram os parâmetros que melhor caracterizaram esses derrames. Da mesma maneira, quando a suspeita clínica é câncer, um líquido serohemorrágico e linfocítico deve ser submetido à citologia oncótica, uma vez que este exame laboratorial de fácil realização e baixo custo apresenta alto desempenho diagnóstico (<FONT FACE=Symbol>@</FONT> 80%). Neste contexto, sugerimos que a toracocentese, com exames bioquímicos e citológicos do líquido pleural, seja a primeira abordagem diagnóstica do paciente.

PURPOSE: To evaluate the clinical and laboratory characteristics of pleural effusions secondary to tuberculosis (TB) or cancer (CA). METHODS: A total of 326 patients with pleural effusion due to TB (n=182) or CA (n=144) were studied. The following parameters were analyzed: patient gender, age and pleural effusion characteristics (size, location, macroscopic fluid aspect, protein concentration, lactate dehydrogenase (DHL) and adenosine deaminase activity (ADA) and nucleated cell counts). RESULTS: Young male patients predominated in the tuberculosis group. The effusions were generally moderate in size and unilateral in both groups. Yellow-citrine fluid with higher protein (p < 0.001) levels predominated in effusions from the tuberculosis group (5.3 + 0.8 g/dL) when compared to the CA group (4.2 ± 1.0 g/dL), whereas DHL levels were more elevated in CA (1,177 ± 675 x 1,030 ± 788 IU; p = 0.003) than in TB. As expected, ADA activity was higher in the TB group (107.6 ± 44.2 x 30.6 ± 57.5 U/L; p < 0.001). Both types of effusions presented with high nucleated cell counts, which were more pronounced in the malignant group (p < 0.001). TB effusion was characterized by a larger percentage of leukocytes and lymphocytes (p < 0.001) and a smaller number of mesothelial cells (p = 0.005). Lymphocytes and macrophages were the predominant nucleated cell in neoplastic effusions. CONCLUSION: Our results demonstrate that in lymphocytic pleural exudate obtained from patients with clinical and radiological evidence of tuberculosis, protein and ADA were the parameters that better characterize these effusions. In the same way, when the clinical suspicion is malignancy, serous-hemorrhagic lymphocytic fluid should be submitted to oncotic cytology once this easy and inexpensive exam reaches a high diagnostic performance (<FONT FACE=Symbol>@</FONT> 80%). In this context, we suggest thoracocentesis with fluid biochemical and cytological examination as the first diagnostic approach for these patients.

O derrame pleural recidivante é uma situação clínica comum que compromete a qualidade de vida dos pacientes, em especial dos portadores de doença oncológica em estágio avançado. A abordagem terapêutica do espaço pleural é variada, incluindo procedimentos agressivos como a pleurectomia. A pleurodese é a técnica mais freqüentemente utilizada, podendo ser induzida tanto através da inserção de cateteres pleurais, como por procedimentos cirúrgicos amplos (toracotomia). São vários os agentes esclerosantes indicados, incluindo o talco, que é o mais utilizado, o nitrato de prata e recentemente as citocinas proliferativas. Este artigo resume as principais abordagens do derrame pleural recidivante e particularmente da pleurodese, suas indicações, vantagens e desvantagens para a aplicação na prática diária do pneumologista.

Recurrent pleural effusion, which is commonly seen in clinical practice, compromises patient quality of life, especially in patients with advanced malignant disease. The therapeutic approach to the pleural space involves a wide range of techniques, including aggressive procedures such as pleurectomy. Among such techniques, pleurodesis is the most frequently used. Pleurodesis can be induced through the insertion of pleural catheters, as well as through major surgical procedures (such as thoracotomy). There are various recommended sclerosing agents, including talc (which is the most widely used), silver nitrate and, recently, proliferative cytokines. This article summarizes the principal approaches to the treatment of recurrent pleural effusion, pleurodesis in particular, addressing the indications for, as well as the advantages and disadvantages of, their application in daily pulmonology practice.