Clinical Characteristics of Tuberculous Empyema

결핵성 농흉의 임상적 특성

  • Shin, Moo Cheol (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Lee, Seung Jun (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Yoon, Seok Jin (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Kim, Eun Jin (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Lee, Eung Bae (Department of Chest Surgery, School of Medicine, Kyungpook National University) ;
  • Cha, Seung Ick (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Park, Jae Yong (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Jung, Tae Hoon (Department of Internal Medicine, School of Medicine, Kyungpook National University) ;
  • Kim, Chang Ho (Department of Internal Medicine, School of Medicine, Kyungpook National University)
  • 신무철 (경북대학교 의과대학 내과학교실) ;
  • 이승준 (경북대학교 의과대학 내과학교실) ;
  • 윤석진 (경북대학교 의과대학 내과학교실) ;
  • 김은진 (경북대학교 의과대학 내과학교실) ;
  • 이응배 (경북대학교 의과대학 흉부외과학교실) ;
  • 차승익 (경북대학교 의과대학 내과학교실) ;
  • 박재용 (경북대학교 의과대학 내과학교실) ;
  • 정태훈 (경북대학교 의과대학 내과학교실) ;
  • 김창호 (경북대학교 의과대학 내과학교실)
  • Received : 2006.03.22
  • Accepted : 2006.04.28
  • Published : 2006.05.30

Abstract

Background : In contrast to tuberculous pleurisy, tuberculous empyema is a chronic active infectious disease of the pleural cavity that is frequently accompanied by cavitary or advanced pulmonary lesions. The condition requires long-term anti-tuberculous medication with external drainage. The clinical features and treatment outcome of tuberculous empyema are unclear despite the high prevalence of tuberculosis in Korea. Methods : From January 1991 through April 2004, 17 patients diagnosed with tuberculous empyema in Kyungpook National University Hospital were enrolled in this study. Their medical records and chest radiographs were reviewed. Results : Twelve patients(71%) had a history of tuberculosis and six of the 12 patients were under current anti-tuberculous medication. Productive cough, fever, and dyspnea were the main complaints. There was no predominance between the right and left lungs. Nine patients(53%) had far-advanced pulmonary tuberculosis, two(12%) had a cavitary lesion, and seven(41%) had a pyopneumothorax on the chest radiograph. All eight cases in whom the data of pleural fluid WBC differential count was available showed polymorphonuclear leukocyte predominance. Eight patients(47%) had other bacterial infections as well. The overall rates of a positive sputum AFB smear and culture for M. tuberculosis were 71% and 64%, respectively. The positive AFB smear and culture rates for M. tuberculosis from the pleural fluid were 33% and 36%, respectively. Twelve of the 16 patients(75%) were treated successfully. Three underwent additional surgical intervention. Two patients (12%) died during treatment. Conclusion : Tuberculous empyema is frequently accompanied by advanced pulmonary lesions, and polymorphonuclear leukocytes are predominant in the pleural fluid. Other accompanying bacterial infections in the pleural cavity are also common in tuberculous empyema patients. Therefore, tuberculous empyema should be considered in differential diagnosis of patients with polymorphonuclear leukocyte-predominant pleural effusion. In addition, more active effort will be needed to achieve a bacteriological diagnosis in the pleural fluid.

배 경 : 결핵성 농흉은 단순 결핵성 흉막염보다 빈도는 낮으나 공동이나 중증 폐결핵과 흔히 동반되 고, 배농과 함께 장기적인 치료를 요하는 흉강의 만성적 활동성 감염질환이다. 국내에서도 이러한 결핵성 농흉 환자가 드물지 않게 발생하고 있으나 지금까지 이에 대한 연구가 거의 없었다. 방 법 : 1991년 1월부터 2004년 4월까지 경북대학교병원에서 결핵성 농흉으로 진단된 17예의 환자를 대상으로 후향적 조사를 시행하였다. 결 과 : 대상환자 17예 중 12예(71%)에서 폐결핵 치료 과거력(6예) 혹은 현재 치료중인 폐결핵(6예)과 관련이 있었으며, 가장 흔한 증상으로는 객담이 동반된 기침, 발열, 호흡곤란의 순이었다. 중증 폐결핵 병변이 53%, 공동성 병변이 12%, 농기흉이 41%에서 관찰되었다. 흉막액 분석이 가능하였던 8예 모두에서 다형핵백혈구 우세의 삼출액이었으며, 세균성 감염이 47%에서 동반되어 있었다. 객담 항산균 도말검사는 71%, 객담 결핵균 배양검사는 64%에서 양성을 보였으며, 흉막액의 항산균 도말검사는 33%, 흉막액 결핵균 배양검사는 36%에서 양성을 보였다. 추적 관찰된 16예 중에서 외과적 치료를 시행한 3예를 포함한 12예(75%)에서 성공적으로 치료되었고, 2예(12%)는 사망하였다. 결 론 : 결핵성 농흉은 농기흉을 동반한 중증의 폐결핵과 흔히 동반되고, 흉막액의 백혈구 감별계산에서 다형핵백혈구 우세를 보이며, 흉막강의 세균성 감염이 흔히 동반되었다. 따라서 심한 폐병변과 동반되어 완전한 농이나 다형백혈구 우세 소견을 보이는 화농성 흉막액 환자에서 결핵성 농흉을 감별진단에 반드시 고려하여 이에 대한 적극적인 조사와 치료가 필요할 것으로 생각된다.

Keywords

References

  1. Leibowitz S, Kennedy L, Lessof MH. The tuberculin reaction in the pleural cavity and its suppression by antilymphocyte serum. Br J Exp Pathol 1973;54:152-62
  2. Leckie WJ, Tothll P. Albumin turnover in pleural effusions. Clin Sci 1965;29:339-52
  3. Seibert AF, Haynes J Jr, Middleton R, Bass JB Jr. Tuberculous pleural effusion: twenty-year experience. Chest 1991;99:883-6 https://doi.org/10.1378/chest.99.4.883
  4. Iseman MD, Madsen LA. Chronic tuberculous empyema with bronchopleural fistula resulting in treatment failure and progressive drug resistance. Chest 1991;100:124-7 https://doi.org/10.1378/chest.100.1.124
  5. Bai KJ, Wu IH, Yu MC, Chiang IH, Chiang CY, Lin TP, et al. Tuberculous empyema. Respirology 1998;3:261-6 https://doi.org/10.1111/j.1440-1843.1998.tb00132.x
  6. Sahn SA, Iseman MD. Tuberculous empyema. Semin Respir Infect 1999;14:82-7
  7. Jess P, Brynitz S, Friis Moller A. Mortality in thoracic empyema. Scand J Thorac Cardiovasc Surg 1984;18:85-7 https://doi.org/10.3109/14017438409099390
  8. Neihart RE, Hof DG. Successful nonsurgical treatment of tuberculous empyema in an irreducible pleural space. Chest 1985;88:792-4 https://doi.org/10.1378/chest.88.5.792
  9. Lee CS. Tuberculous empyema. Tuberc Respir Dis 1955;2:89-95
  10. Lee SY, Kwon SY, Kim DK, Yoo CG, Lee CT, Kim YW, et al. The effects of the decortication on pulmonary function in tuberculous empyema. Tuberc Respir Dis 2000;49:30-6 https://doi.org/10.4046/trd.2000.49.1.30
  11. Kim YS, Kim SM, Kim JH, Lee KS, Yang SC, Yoon HJ, et al. The effect of percutaneous pig-tail catheter drainage in the management of lung abscess and empyema. Tuberc Respir Dis 1996;43:571-8 https://doi.org/10.4046/trd.1996.43.4.571
  12. Williams G, Turton CW, Green M. Empyema presenting over thirty years after pulmonary tuberculosis. Tubercle 1981;62:139-41 https://doi.org/10.1016/0041-3879(81)90023-4
  13. Levine H, Szanto PB, Cugell DW. Tuberculous pleurisy: an acute illness. Arch Intern Med 1968;122:329-32 https://doi.org/10.1001/archinte.122.4.329
  14. Berger HW, Mejia E. Tuberculous pleurisy. Chest 1973;63:88-92 https://doi.org/10.1378/chest.63.1.88
  15. Sibley JC. A study of 200 cases of tuberculous pleurisy with effusion. Am Rev Tuberc 1950;62:314-23
  16. Al-Kattan KM. Management of tberculous empyema. Eur J Cardiothorac Surg 2000;17:251-4 https://doi.org/10.1016/S1010-7940(99)00370-X
  17. Alfageme I, Munoz F, Pena N, Umbria S. Empyema of the thorax in adults: etiology, microbiologic findings, and management. Chest 1993;103:839-43 https://doi.org/10.1378/chest.103.3.839
  18. LeMense GP, Strange C, Sahn SA. Empyema thoracis: therapeutic management and outcome. Chest 1995;107:1532-7 https://doi.org/10.1378/chest.107.6.1532
  19. Sendt W, Forster E, Hau T. Early thoracoscopic debridement and drainage as definite treatment for pleural empyema. Eur J Surg 1995;161:73-6