• Tuberculosis and Respiratory Diseases
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• v.59 no.4
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• pp.361-367
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• 2005

Background : Differential diagnosis of lymphocytic pleural effusion is difficult even with many laboratory findings. Nitric oxide(NO) level is higher in the sputum or exhaled breath of patients with active pulmonary tuberculosis than in those without tuberculosis. In addition, there are some reports about the increased level of NO metabolites in body fluids of cancer patients. However, there is no data on the NO levels in the pleural fluid of patients with tuberculous pleurisy. Method : The serum and pleural fluid NO in the patients with acute lymphocytic pleural effusion were analyzed. Results : Of total 27 patients, there were 14 males and average age of patients was 48 years. The final diagnosis was tuberculous pleurisy in 17 cases and malignant pleural effusion in 10. The pleural fluid NO level was $540.1{\pm}116.4{\mu}mol$ in the tuberculous pleurisy patients and $383.7{\pm}71.0{\mu}mol$ in the malignant pleural effusion patients. The serum NO level was $624.7{\pm}142.0{\mu}mol$ in tuberculous pleurisy patients and $394.4{\pm}90.4{\mu}mol$ in malignant pleural effusion patients. There was no significant difference in the serum and pleural fluid NO level between the two groups. The NO level in the pleural fluid showed a significant correlations with the pleural fluid neutrophil count, the pleural fluid/serum protein ratio, and pleural fluid/serum albumin ratio (p<0.05 in each). The protein concentration, leukocyte and lymphocyte count in the pleural fluid were significantly higher in the tuberculous pleurisy patients than the malignant pleural effusion patients (p<0.05 in each). Conclusion : NO is not a suitable marker for a differential diagnosis of lymphocytic pleural effusion. However, the NO level in the pleural fluid might be associated with the neutrophil recruitment and protein leakage in the pleural space.

• Tuberculosis and Respiratory Diseases
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• v.55 no.4
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• pp.353-360
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• 2003

Background : Although most patients with tuberculous pleurisy respond well to anti-tuberculous drugs, some are known to progress into severe pleural thickening which needs decortication despite adequate anti-tuberculous treatment. Therefore, the purpose of this study was to identify factors associated with the development of severe pleural thickening in patients who finally underwent pleural decortication in tuberculous pleurisy. Patients and Methods : From retrospective medical records review, 121 patients initially diagnosed as tuberculous pleurisy without initial pleural fluid loculation were enrolled between January 1998 and December 2002. They were separated into two groups: 85 patients in group 1 who improved by anti-tuberculous drugs only, and 36 patients in group 2 who had progressed into pleural adhesion and finally underwent pleural decortication despite adequate (more than 6 months) anti-tuberculous treatment. Results : Males were more common in group 2 (M/F=31/5) than in group 1 (M/F=53/32) (p=0.010). Group 2 patients tended to have lower pleural fluid glucose level ($58{\pm}4$ mg/dL) than group 1 ($89{\pm}3$ mg/dL) (p=0.001) and higher pleural fluid adenosine deaminase level ($86{\pm}5$ IU/L) than group 1 ($76{\pm}3$ IU/L), (p=0.038). There were no significant differences in age, symptom duration, pleural fluid amount, or pleural fluid LDH level between groups 1 and 2. Conclusions : There was a relative risk of tuberculous pleurisy progression into severe pleural thickening which needed decortication in the case of male patients, low pleural fluid glucose or high adenosine deaminase level. But further, large-scale, prospective studies should be investigated.

• Journal of Chest Surgery
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• v.21 no.6
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• pp.1111-1116
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• 1988

Neurofibromatosis is very rare syndrome characterized by abnormal cutaneous pigmentation and numerous skin tumors was described by Smith in 1849, which is inherited as an autosomal dominant trait. Von Recklinghausen reported 2 cases of multiple skin and subcutaneous tumors in 1982. Malignant peripheral nerve tumors, although generally rare, are one of the most characteristic malignant tumors associated with Neurofibromatosis. We have experienced 3 cases of malignant Schwannoma in neurofibroma patients from 1982 to 1988 for 6 years at Thoracic and Cardiovascular surgery department, College of Medicine, Yonsei University, Seoul, Korea. l. One is 62 years old female who was taken total hysterectomy followed by irradiation treatment due to Uterine Carcinoma 21 years ago. She had a large bulging mass on left anterior chest wall and was taken enbloc resection of tumor including rib confirmed malignant Schwannoma. 2. Another is 18 years old female who had large bulging mass on right chest wall and pleural effusion in right thoracic cavity. Thoracentesis revealed a large amount of lymphocytes misdiagnosed of Tbc, pleurisy with Neurofibromatosis. We performed tissue biopsy on bulging mass and the specimen was confirmed malignant Schwannoma 2 months after first diagnosis of Tbc. pleurisy. She was not accessible to radical resection because of far advanced malignant Schwannoma at that time. 3. Third case is 28 years old male who was taken enbloc resection of tumor including rib due to Neurofibroma with Neurofibromatosis at M. hospital 6 months ago. But he had rapid growing mass at operation site again and taken tissue biopsy confirmed of malignant Schwannoma. He was not accessible to enbloc resection due to malignant Schwannoma extending to mediastinal structures.

• The Journal of Internal Korean Medicine
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• v.22 no.3
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• pp.489-494
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• 2001

Pneumonia is the disease caused by inflammation of lung parenchyma. Major symptoms of pneumonia are fever, cough, etc and consolidation is seen in chest x-ray. When pleurisy gets in complication of pneumonia, pleural effusion occurs. Also chest pain occurs by pleurisy. Gyulhyung is the disease of which major symptom is chest pain. Sugyulhyung from in Gyulhyung, the water sound is audible from the flank side the fact that as Sugyulhyung. Symptom of Gyulhyung is similar to that of pneumonia. We diagnosed this case as Gyulhyung and administrated Banhabogryeongtang to patient. As result, there is remarkable Improvement in symptom and chest x-ray.

• Tuberculosis and Respiratory Diseases
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• v.44 no.1
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• pp.52-58
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• 1997

Background : Tuberculous pleurisy has been treated With a combined regimen of corticosteroids- antimicrobial therapy. But whether such combination therapy add to benefits is unknown. We evaluate the effects of corticosteroid and its routine application in relief of clinical symptoms, absorption of pleural effusion, and pleural adhesions. Methods : A prospective, randomized study of the role of corticosteroid in the treatment of tuberculous pleurisy was performed in 83 patients(nonsteroid group: 50 patients, steroid group: 33 patients) from June, 1991 to September, 1994. Results : 1) The mean duration from symptoms(fever, chest pain, dyspnea) to relief was 3.8 days in the steroid group, and 7.4 days in the nonsteroid group(P<0.05). Clinical symptoms including fever, chest pain, sputum and weight loss were relieved more rapidly in the steroid group than other symptoms(weakness, night sweating and dyspnea). 2) Pleural effusion was taken an averge of 88 days in the steroid group and 101 days in the nonsteroid group 10 be absorbed completely(p>0.05) 3) The incidence of pleural adhesions was 17/33(5l.5%) in the steroid group and 32/50(64%) in the nonsteroid group(p>0.05) 4) Side effects of corticosteroids were observed in only one patient causing epigastric pain and discontinuation of drug. Conclusion : Corticosteroid exert benefitial role in the more rapid relief of clinical symptoms to patients with tuberculous pleurisy, but absortion of pleural effusion and occurrence of pleural adhesions was not influenced significantly Therefore, its routine application should be reevaluated.

• Tuberculosis and Respiratory Diseases
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• v.59 no.2
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• pp.186-192
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• 2005

Background : Diagnosis of tuberculous pleurisy is sometimes difficult using conventional diagnostic methods. We have investigated the utility of pleural fluid cell $IFN-{\gamma}$ production assay in the diagnosis of tuberculous pleurisy. Methods : We prospectively performed pleural fluid cell $IFN-{\gamma}$ production assay in 39 patients with tuberculous pleural effusions (TPE) and in 26 patients with nontuberculous pleural effusions (NTPE) (13 malignant pleural effusions and 13 parapneumonic effusions). Pleural fluid cells were cultured in DMEM media and stimulated with purified protein derivatives (PPD), and phytohemagglutinin (PHA) for 24 hr. The amount of $IFN-{\gamma}$ released in the culture supernatant was quantitated by $IFN-{\gamma}$ ELISA assay. We have also measured adenosine deaminase (ADA) activities and $IFN-{\gamma}$ concentrations in the pleural fluid. Results : 1) The pleural fluid levels of ADA activity and $IFN-{\gamma}$ concentrations were significantly higher in TPE than NTPE (p<0.01). 2) $IFN-{\gamma}$ production in TPE cells stimulated by PPD ($755,266{\pm}886,636pg/ml$) was significantly higher than NTPE cells ($3,509{\pm}6,980pg/ml$) (p<0.01). By considering the fact that $IFN-{\gamma}$ concentrations over 10,000 pg/ml is a criteria for the diagnosis of TBE, sensitivity and specificity of the test were 97.4 and 92.3%, respectively. 3) The ratios of $IFN-{\gamma}$ production by the stimulation with PPD and PHA (PPD/PHA) were significantly higher in TPE cells ($59{\pm}85$) than NTPE cells ($5{\pm}18$)(p<0.01). Considering the criteria for the diagnosis of TBE as PPD/PHA ratio over 5, sensitivity and specificity of the test were 76.9 and 92.3%, respectively. Conclusion : Pleural fluid cell $IFN-{\gamma}$ production assay may be useful for the diagnosis of tuberculous pleurisy.

• Tuberculosis and Respiratory Diseases
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• v.53 no.1
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• pp.27-35
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• 2002

Background : The paradoxical response refers to an enlargement of old lesions or unexpected new ones during apparently adequate antituberculous therapy. This response has been reported in cases of intracranial tuberculoma, tuberculous lymphadenopathy, tuberculous pleurisy and pulmonary tuberculosis. However, there are few reports on its frequency and clinical characteristics. Materials and Methods : This study enrolled 205 patients who were treated with first line antituberculous agents for more than 6 months. We retrospectively studied 155 patients with pulmonary tuberculosis and 57 patients with pleural tuberculosis (7 patients had both) from July 1998 to March 2000. The patients were divided into the paradoxical response group and the non-paradoxical group. The clinical characteristics of the paradoxical response group and the non-paradoxical group. The clinical characteristics of the paradoxical group were investigated. Statistical analysis was done with an independent sample T-test and Chi-squared test. Results : 29 of the 205 patients(14.1%) had paradoxical response. Among the 29 patients, there were 19 pulmonary tuberculosis, 8 tuberculous pleurisy(2 patients had both). Paradoxical response appeared 32 days (mean 35 days in pulmonary tuberculosis, mean 25 days in tuberculous pleurisy) after the beginning of chemotherapy. The duration to regress less than half of initial chest lesion was 114 days in pulmonary tuberculosis and 124 days in tuberculous pleurisy, respectively. Most common clinical manifestation of paradoxical response patients was coughing in both pulmonary tuberculosis and tuberculous pleurisy. Male sex, high blood WBC count and high level of pleural fluid LDH were related with paradoxical response. Conclusion : These findings suggest that presponse usually appears 1 month and disappears within 4 months after the beginning of anti-tuberculous chemotherapy. Paradoxical response was relatively correlated with male sex, high blood WBC count and high level of pleural fluid LDH.

• Tuberculosis and Respiratory Diseases
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• v.46 no.1
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• pp.17-24
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• 1999

Background : A sizable percentage of tuberculous pleurisy patients are known to have residual pleural thickening(RPT) despite adequate anti-tuberculous chemotherapy. But, the predictive factors related to the development of RPT is not well known. Therefore, we studied to determine which factors are related to the development of RPT after completion of therapy. Methods: By retrospective review of medical records, fifty-eight patients initially diagnosed as having tuberculous pleurisy between March 1995 and January 1998 were separated into two groups : 27 patients in group 1 had RPT on simple chest radiography, while 31 patients in group 2 had no RPT after 6 month of anti-tuberculous chemotherapy. The clinical characteristics, radiologic findings and pleural fluid findings of the two group were compared at the time of diagnosis and during the course of therapy. Results: 47% of patients had RPT after 6 month of chemotherapy, and RPT was more common in man than in women(54% vs 29%, p=0.092). In group 2 patients, complete resorption of pleural lesion occurred rather late stage of therapy(1-2 month: 26%, 3-4 month: 29%, 5-6 month: 45%). Group 1 patients had increased percentage of loculated pleural lesion(26 % vs 19%) and increased white blood cell and lymphocyte count, lactate dehydrogenase level in pleural fluid ($3527\pm5652$ vs $2467\pm2201$/ml, $2066\pm2022$ vs $1698\pm1835$/ml and $1636\pm1143$ vs $1441\pm923$IU/mL respectively) than group 2 at the time of diagnosis, but statistically insignificant. Duration of symptom prior to treatment, size of pleural effusion, presence of parenchymal lung lesion, level of total protein, glucose and adenosine deaminase(ADA)activity in pleural fluid were similar in both group. Conclusion: 53% of tuberculous pleurisy patients showed slow but complete resorption of pleural lesion after 6 month of chemotherapy. But, no clinical, radiological and pleural fluid findings are predictive for the development of RPT.

• Tuberculosis and Respiratory Diseases
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• v.64 no.6
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• pp.427-432
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• 2008

Background: A paradoxical response is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion after initial improvement during theprocess of antituberculous treatment. The related factors for the development of a paradoxical response in patients with tuberculous pleurisy are not certain. Methods: We selected patients with tuberculous pleurisy who had been treated for more than 4 months. The changes onthe serial chest X-ray findings before and after treatment were reviewed. Paradoxical responses were regarded as any worsening or development of new lesion at least 2 weeks after the initiation of treatment. The baseline clinical characteristics and laboratory findings of the peripheral blood and pleural fluid were compared between the patients with a paradoxical response and the patients without a paradoxical response. Results: Paradoxical responses appeared in sixteen patients (21%) among the 77 patients.It took a mean of 38.6 days after the treatment and the time to resolve the paradoxical response was a mean of 32.1 days. For the patients with a paradoxical response, the median age was younger (30.5 years vs 39.0 years, respectively) and the lymphocytic percentage of white blood cells in the pleural fluid was higher (82.1% vs 69.6%, respectively) than for the patients without a paradoxical response. Conclusion: The development of a paradoxical response during the treatment of patients with tuberculous pleurisy was not rare and this was related with the age of the patients and the percentage of lymphocytic white blood cells in the pleural fluid.

• Tuberculosis and Respiratory Diseases
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• v.44 no.1
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• pp.44-51
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• 1997

Background : The changes of the composition in the T-lymphocyte are important as an immunological abnormality in the pathogenesis of tuberculosis. Previously, the second type of TCR dimer(${\gamma}{\delta}$ T lymphocyte) that did not express CD4 or CD8 molecules was found. In other reports the presence of this type of lymphocytes was increased in the initial stage of tuberculous infections. Method : To determine whether there are some differences in the T-lymphocyte subsets in the peripheral blood or pleural effusion between pleural tuberculosis and other pleurisy. Thirty patients with pleural effusion among the forty-nine patients were examined T-lymphocyte subset analysis(CD4+T-cell,CD8+ T-cell,${\gamma}{\delta}$ T-lymphocytes) with anti- Leu4, anti-Leu3a, anti-Lea2a, anti HLA-DR and anti-TCR-${\gamma}{\delta}$-1(Becton & Dickinson Co.). Results : The average age of the patients was 50 years old(17-81year). There were 33 males and 16 female patients. Patiensts with tuberculosis are 30cases(tuberculous pleurisy 15), lung cancer 12cases(malignant effusion 9) and pneumonia 7cases(parapneumonic effusion 6cases) In T lymphocyte subsets of pleural effusion, helper T lymphocyte(54.6 + 13.8 %) of tuberculous pleurisy was higher than that(36.2 + 25.3 %) of non-tuberculous pleurisy(p=0.04). The peripheral blood ${\gamma}{\delta}$ T-lymphocytes in tuberculousis was insignificantly higher than non-tuberculous patients(p= 0.24). The peripheral blood ${\gamma}{\delta}$ T-lymphocytes and pleural ${\gamma}{\delta}$ T-Iymphocytes in tuberculous pleurisy was insignificantly higher than in non-tuberculous pleurisy(p= 0.16, p= 0.12). Conclusion : The percentage of -${\gamma}{\delta}$ T lymphocytes among the total T-lymphocytes is not significantly increased in the peripheral blood or pleural effusion of the pleural tuberculosis. ${\gamma}{\delta}$ T lymphocytes is less useful as a diagnostic method of pleural tuberculosis.