Pleural and Parenchymal Radiological Characteristics of Tuberculous Pleuritis and Correlation with Microbiological Diagnostic Yield

Pleural and Parenchymal Radiological Characteristics of Tuberculous Pleuritis and Correlation with Microbiological Diagnostic Yield | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pleural and Parenchymal Radiological Characteristics of Tuberculous Pleuritis and Correlation with Microbiological Diagnostic Yield Si Ling Young, Brian Lee Wei Chua, Qiao Li Tan, Carrie Kah Lai Leong, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7350627/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2025 Read the published version in BMC Pulmonary Medicine → Version 1 posted 15 You are reading this latest preprint version Abstract Introduction Tuberculous (TB) pleuritis is a common extrapulmonary manifestation of the disease, with significant healthcare burden and morbidity. While there is increasing use of computed tomography (CT) scans for evaluation of patients with suspected TB pleuritis, little is known regarding the correlation of CT findings and respiratory and pleural specimen microbiological yield. Methods We performed a retrospective analysis of radiological features and microbiological yield from different diagnostic modalities in patients with TB pleuritis from January 2021 to December 2024. Results A total of 80 patients were included in this study, with 78.8% male and a median age of 62 (interquartile range: 45-73 years). Approximately half (53.8%) of patients had parenchymal abnormalities on chest radiographs. CT imaging was performed in 67 patients, of whom 80.6% (54/67) had pleural thickening or nodularity, and 82.1% (55/67) had features of active pulmonary TB. M. Tuberculosis Complex (MTC) was isolated from sputum culture in 33.3% (11/33) of patients with CT features of active pulmonary TB, compared to 0% (0/5) in patients without. A higher proportion of patients with pleural thickening or nodularity on CT had MTC isolated from pleural biopsy samples, compared to patients without (84.0% vs 25.0%, p=0.010). There was no difference in the yield of pleural fluid TB culture between patients with and without pleural abnormalities on CT imaging (48.1% vs 50.0%, p=0.908). Conclusions CT features of active pulmonary disease or pleural thickening are common with TB pleuritis, and are useful to guide the diagnostic workup of patients with suspected TB pleuritis. Figures Figure 1 Figure 2 Introduction and background Tuberculosis (TB) remains one of the leading infectious cause of death in the world over the past decade, second only to the COVID-19 pandemic between the years 2020 to 2022, with a significant healthcare burden worldwide 1 . Despite advances in the treatment of TB, the World Health Organization’s annual report on tuberculosis report an overall rise of TB incidence globally 2 . Of all cases of TB, tuberculous pleuritis (TB pleuritis) accounts for a significant proportion of the disease presentation, ranging from 2.2 to 31.4% 3,4 . It remains the second most common cause of extrapulmonary TB involvement, behind TB lymphadenitis, accounting for about 25% of these cases 5 . The exact pathophysiology of TB pleuritis remains unclear but is thought to be due to either primary or reactivated disease. The postulated mechanism in primary disease involves the TB bacilli entering the pleural space after rupture of a subpleural caseous foci 6 . This incites a delayed hypersensitivity reaction, resulting in an exudative process 7 . TB pleuritis may also result from reactivation following latent TB infection, but these two entities are difficult to differentiate clinically as patients present similarly 8 . TB pleuritis is hence thought to be closely associated with pulmonary TB given its postulated pathogenesis. However, the reported prevalence of concomitant pulmonary disease (based on the presence of radiographic parenchymal abnormalities) ranges widely from 8–50% 9–11 . Even in studies that looked at the role of computed tomography (CT) imaging of the thorax in TB pleuritis, a similar wide range of prevalence of parenchymal disease, from 8–86% 9,12,13 , was reported. Studies report a diagnostic yield of up to 50% with sputum acid-fast-bacilli (AFB) cultures in patients with TB pleuritis 14 , however, it is unclear if these radiographic evidence of parenchymal disease correlate with the microbiological yield of respiratory specimens. The diagnostic yield of pleural fluid microbiology, both AFB smear and culture, and polymerase chain reaction (PCR), is also recognized to be poor. The yield of pleural fluid AFB smear is less than 10%, and AFB culture less than 30% 15 , but is higher in immunosuppressed patients with retroviral disease 16 , 17 . Aside from retroviral disease, it is uncertain if there are other factors that influence the yield of pleural microbiology, in particular with regards to pleural changes on imaging. The most commonly described CT pleural abnormality in TB pleuritis is that of a diffuse thickening of the pleura 7 , 18 , of which Kim et al. reported in 32.6% of patients in their study of CT chest findings of TB pleuritis. Whether these pleural abnormalities have any correlation with the pleural fluid or tissue microbiology is unknown. Our study hence aims to describe the CT parenchymal and pleural abnormalities in our patient cohort with TB pleuritis, and evaluate the microbiological yield of sputum, and pleural fluid and tissue respectively. Methods A retrospective analysis of patients with TB pleuritis diagnosed at a tertiary hospital in Singapore was performed. A definite diagnosis of TB pleuritis was made in patients who had pleural effusion and a positive sputum, pleural fluid or tissue microbiology for Mycobacterium Tuberculosis Complex (MTC), either in the form of AFB staining or culture or TB PCR, or tissue histology demonstrating necrotizing granulomatous inflammation. A presumptive diagnosis of TB pleuritis was made in patients who had a lymphocytic exudative pleural effusion with raised adenosine deaminase (ADA), which was defined as > 30 units/L, and a clinical and radiological response to anti-tuberculous treatment. All patients with a definite or presumptive diagnosis of TB pleuritis during January 2021 to December 2024 were included in this analysis. As this study was performed with anonymized data retrieved from a clinical audit, it was exempted from formal institutional review board approval. Data on patient baseline characteristics, radiological and microbiological results were collected. Radiological evaluation of chest radiographs and CT imaging of the thorax were performed by respiratory consultants (S.L.Y. and K.J.G.) with reference to the formal radiological reports by the hospital’s radiologists. The definitions of radiological abnormalities were adopted from the Fleischner glossary 19 , namely for consolidation, ground glass opacities, nodules and masses. The effusion sizes as determined on chest radiograph are defined as follows: Small refers to effusions less than 25% of the hemithorax, moderate refers to effusions occupying 25–50% of the hemithorax, large refers to effusions occupying 50–75% of the hemithorax, and massive refers to effusions larger than 75% of the hemithorax or with evidence of mediastinal shift. Loculated effusions refer to effusions that show features of non-gravity dependence. The presence of parenchymal abnormalities on chest radiograph was determined based on the film performed after the effusion was mostly drained. Representative images are included in the appendix for further reference. Data analysis was performed on SPSS version 23. Descriptive statistics of the variables were expressed with in median with interquartile range (IQR), or numbers with percentage. Discrete variables were analysed with chi-square test (or Fischer’s exact test) and continuous variables were analysed with Mann-Whitney-U test. P values of less than 0.05 were considered to be statistically significant. Data from the study are not publicly available due to privacy restrictions. Requests for access should be directed to the corresponding author. Results We included a total of eighty patients in our study analysis. The majority of the patients were male (78.8%), with a median age of 63 (interquartile range (IQR): 45–73) years. Sixty-three patients (78.8%) were diagnosed with TB pleuritis based on a positive sputum or pleural (fluid or tissue) microbiology demonstrating MTC on culture. Five patients (6.3%) with no MTC isolated on culture were diagnosed based on the presence of necrotizing granulomatous inflammation on histology, and the remaining 12 patients (15.0%) had a presumptive diagnosis of TB pleuritis. Table 1 describes the characteristics of our cohort of patients with TB pleuritis. Chest radiograph features In terms of chest radiographic characteristics, most effusions were right sided (67.5%) and moderate in size (41.3%). A significant proportion of patients also presented with large or massive effusions (18.8% and 12.5% respectively). Approximately half the cohort (53.8%) had parenchymal abnormalities noted on the chest radiograph. The majority of parenchymal abnormalities were located in the upper zone (67.4%, 29/43), and were consolidative in nature (67.4%, 29/43) (Fig. 1 ). A larger proportion of patients with small or moderate effusions had parenchymal abnormalities on chest radiograph, compared to patients with large or massive effusions (65.5% (36/55) vs 28.0% (7/25), p = 0.002). Sputum microbiology A total of forty-five patients had sputum specimens sent for microbiological assessment, of which forty-four patients had sputum AFB smear and culture performed, and thirty-eight patients had sputum TB PCR performed. Eleven patients (25.0%, 11/44) had an AFB culture result positive for MTC and six patients (15.8%, 6/38) had a positive TB PCR result. The yield of sputum culture for MTC was 31.0% (9/29) in patients with chest radiographic parenchymal abnormalities, and 13.3% (2/15) in patients with no parenchymal abnormalities on chest radiograph (p = 0.199) (Table 2 ). CT imaging features Of the whole cohort, sixty-seven patients had CT thorax performed as part of their workup. Forty-two patients (62.7%, 42/67) had diffuse pleural thickening observed on CT and twelve (17.9.0%, 12/67) had nodular or irregular pleural thickening seen. The most common parenchymal abnormality observed on CT was consolidation, with thirty patients (47.8%, 32/67) having ipsilateral consolidation, three (4.5%, 3/67) contralateral, and five (6.0%, 4/67) with bilateral consolidative change. The next most common was tree-in-bud or centrilobular nodularities (35.8%, 24/67), followed by non-calcified lung nodules with or without cavitation (32.8%, 22/67). Fifty-five patients (82.1%, 55/67) had parenchymal abnormalities that were suggestive of active pulmonary TB disease (Fig. 1 ). This was defined as the presence of consolidation, lung nodules, tree-in-bud or centrilobular nodularities or perifissural nodules, with reference to the definitions used by Kim et al. in their study on pulmonary parenchymal tuberculosis in TB pleuritis 12 . Of these sixty-seven patients with CT imaging performed, thirty-eight patients had sputum sent for microbiological evaluation. Sputum microbiology seems to be positively correlated with the presence of active CT parenchymal abnormalities, though this was not a statistically significant result (33.3%, (11/33) vs 0.0% (0/5), p = 0.126) (Table 2 ). There was no statistically significant correlation between sputum microbiological positivity and parenchymal consolidation, tree-in-bud nodularities, or lung nodules individually. Pleural fluid and tissue microbiology Seventy-nine and sixty-four patients had pleural fluid sent for AFB culture and TB PCR respectively. A total of thirty-eight patients had pleural biopsies performed, which were analysed for AFB smear and culture and/or histology. Thirty patients had pleural tissue TB PCR performed. The yield of pleural fluid and tissue AFB culture was 50.6% (40/79) and 78.4% (29/37) respectively. When comparing the yield of pleural fluid AFB culture in patients with and without CT pleural abnormalities, there was no statistically significant difference found (48.1% vs 50.0%, p = 0.908). However, the yield of pleural tissue AFB culture was significantly higher in patients with CT pleural abnormalities, compared to patient with no pleural nodularity or thickening seen on CT (84.0% (21/29) vs 25.0% (1/4), p = 0.010) (Table 2 ). A total of seventy-nine patients had either sputum or pleural fluid samples sent for AFB smear and culture or TB PCR, of whom forty-nine (62.0%) patients had either at least one positive microbiology yield from either sputum or pleural fluid samples. Thirty-eight patients had pleural tissue analysed for either AFB smear and culture, histology or TB PCR, of whom thirty-five (92.1%) had a conclusive test for the diagnosis of TB pleuritis (Fig. 2 ). Discussion To our knowledge, this is the first study describing the microbiological yield of sputum and pleural investigations in relation to CT thorax findings. While the diagnosis of TB pleuritis remains challenging, the increasing accessibility to CT scans provides valuable information that can further improve the diagnostic approach to patients with suspected TB pleuritis. In this study, in 67 patients with CT imaging performed, up to 80.6% and 82.1% were found to have pleural thickening and features of active pulmonary TB on CT imaging, respectively. Furthermore, we report an association between pleural abnormalities (thickening and nodularity) on CT with a higher microbiological yield for TB pleuritis following pleural biopsy. There also appears to be a trend towards a higher sputum microbiological yield in patients with lung parenchymal abnormalities seen on CT imaging. The prevalence of concomitant pulmonary TB in our cohort was 53.8%, based on the presence of chest radiographic parenchymal abnormalities. This is slightly higher than the majority of studies which report 17–30% 17,20,21 coexistent pulmonary disease based on chest radiographs. This may be because our study assessed the parenchymal changes based on the radiographs that were performed after pleural interventions, hence reducing the possibility that the effusion was obscuring the parenchymal lesions. However, we recognize that there may be a small possibility that the parenchymal changes appreciated after a pleural intervention are related to re-expansion pulmonary edema, although this is rare 22 and mitigated by controlled drainage post-intervention. Despite this, chest radiographic evidence of parenchymal disease still likely underestimates the actual prevalence of concomitant pulmonary TB, given that 82.1% of patients with CT in our study had changes suggestive of active pulmonary disease. This is similar to most existing studies reporting concomitant pulmonary TB on CT in 74–86% of cases 12 , 23 , and further corroborates the finding that CT is more sensitive in identifying parenchymal disease than chest radiographs in TB pleuritis 24 , 25 . Importantly, there is suggestion of a higher yield of sputum microbiology in patients with CT parenchymal disease in our study. In our literature review, there was only one similar study performed by Lee et al., which was a prospective study evaluating the yield of bronchial aspirates (BA) via bronchoscopy in patients with suspected TB pleuritis 23 . They found that there was positive BA microbiology in patients with pulmonary lesions on CT in 65% of cases, compared to 7% in those without. Our findings mirror this positive correlation, even in expectorated sputum. 31.0% of our patients with chest radiographic parenchymal abnormalities had positive sputum mycobacterial culture, compared to 12.5% of patients with no parenchymal changes. Although this was not a statistically significant difference, this mirrors existing studies describing a yield of 30–33% in patients with chest radiographs demonstrating parenchymal involvement, as opposed to 9% in those without 6 , 26 . The study performed by Conde et al. stands out as having a significantly higher microbiological yield of 45–55% using induced sputum, regardless of chest radiographic parenchymal disease 14 . This could be due to sputum induction being performed on all patients in the study, which has a reported yield of more than 60% in patients who are unable to expectorate sputum 27 . To the best of our knowledge, there are no studies directly comparing the yields of sputum and induced sputum. The high induced sputum microbiological yield of 55% in patients without no parenchymal disease on chest radiograph reported by Conde et al. was also inconsistent with our study as well as other existing ones. We postulate that this could be due to two reasons: Firstly, that the sensitivity of a chest radiograph may be too low to adequately identify parenchymal changes secondary to pulmonary TB, and secondly, that there were more patients with moderate or large effusions (39.0%) in the group with no parenchymal changes compared to the group that had parenchymal disease (20%) in that study. Hence, these patients could have parenchymal disease, but were not appreciated given the larger effusions. Another key finding that our study reports is the positive correlation between CT pleural abnormalities and pleural tissue microbiology, but not with pleural fluid microbiology – To our knowledge, this is a novel and unique finding that has not been previously reported in literature. The diagnostic yield of pleural tissue (defined as either positive mycobacterial or histological result) is high, ranging from 60 to over 90% depending on procedural tool used 7 , 18 . Although the demonstration of necrotizing granulomatous inflammation on pleural tissue is generally taken to be diagnostic of TB pleuritis, there are other possible pathogenic causes to consider based on patient demographics and disease endemicity 28 , 29 , and mycobacterial culture is key to demonstrating the offending pathogen and obtaining culture sensitivities. Our findings suggest that in the presence of CT pleural abnormalities in a patient with suspected TB pleuritis, microbiological diagnosis to guide anti-tuberculous treatment is best approached by obtaining pleural tissue, as the pleural tissue AFB culture yield is much higher than other modalities. Pleural fluid alone does not predict microbiological yield, even in the presence of pleural disease on CT. This finding should also ideally be validated in larger cohorts, and may aid in further diagnostic algorithms in TB pleuritis. There are limitations to our study. This was a single center retrospective study with a relatively small population size, with only half the cohort having respiratory specimens sent for microbiology and four-fifths having had CT performed. This is most likely the reason why some of our results did not achieve statistical significance. However, the results of our study echo existing literature, and provide further insights into the various microbiological yields. We also did not conduct sputum induction or bronchoscopy for all patients, but we believe the use of expectorated sputum reflects real-life practice and limitations more accurately. This study also did not evaluate the use of thoracic ultrasound in TB pleuritis, which is increasingly being utilized to guide treatment decisions in undiagnosed pleural effusions 30 , 31 . Hence, larger prospective studies are needed to validate these results and incorporate thoracic ultrasound findings to diagnostic approaches for suspected TB pleuritis. Conclusion A significant proportion of patients with TB pleuritis will have radiological features of active pulmonary TB on CT imaging. These CT abnormalities appear to be associated with a positive sputum culture for TB, but this needs to be evaluated in a larger study. Pleural tissue biopsy for culture and histology has by far the highest diagnostic yield for TB, and interestingly, pleural thickening on CT imaging was significantly associated with a positive pleural tissue AFB culture. Diagnostic imaging therefore holds promise in improving and personalising diagnostic pathways for patients with TB pleuritis, but well-designed prospective studies are needed to establish this. Declarations Ethics approval and consent to participate The study protocol was submitted to the institutional review board (SingHealth Centralised IRB 2025-0373). Informed consent for this analysis was waived and the study was exempted from formal review, as this was a retrospective analysis with anonymized data. The study was conducted in accordance with the principles of the Declaration of Helsinki. Data availability Data from the study are not publicly available due to privacy restrictions. Requests for access should be directed to the corresponding author. Consent for publication Not applicable Availability of data and materials Not applicable Clinical trial number: Not applicable Competing interests The authors declare that they have no competing interests. Funding Not applicable Authors’ contributions S.L.Y. and K.J.G. conceived of the presented idea and devised the project. S.L.Y., B.L.W.C., Q.L.T., C.K.L. and K.J.G. processed the data and performed the analysis. S.L.Y., B.L.W.C., Q.L.T., C.K.L., J.J.Y.W., I.G.C.S.P., W.T.L. and K.J.G. contributed to the interpretation of the results. S.L.Y., B.L.W.C. and K.J.G. wrote the manuscript with input from all authors, and S.L.Y. designed the figures. Acknowledgements Not applicable References World Health Organization. Global Tuberculosis Report 2024: TB mortality. 2024. Published 2024. Accessed July 22, 2025. https://www.who.int/teams/global-programme-on-tuberculosis-and-lung-health/tb-reports/global-tuberculosis-report-2024/tb-disease-burden/1-2-tb-mortality World Health Organization. Global Tuberculosis Report 2024: TB incidence. 2024. Published 2024. Accessed July 22, 2025. https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2024/tb-disease-burden/1-1-tb-incidence Chan KKP, Lee YCG. Tuberculous pleuritis: clinical presentations and diagnostic challenges. Curr Opin Pulm Med. 2024;30(3):210–6. 10.1097/MCP.0000000000001052 . 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Characteristics of patients with TB pleuritis n=80 Gender – Male Age 63 (78.8%) 63 (IQR: 45 - 73) Effusion CXR Characteristics Location – Right Size Small Moderate Large Massive Parenchymal abnormality 54 (67.5%) 22 (27.5%) 33 (41.3%) 15 (18.8%) 10 (12.5%) 43 (53.8%) Effusion CT Characteristics (n=67) Pleural thickening Diffuse Nodular or irregular Loculated effusion 42 (62.7%) 12 (17.9%) 53 (66.3%) Pleural intervention Thoracentesis Chest drain Closed or ultrasound guided pleural biopsy Thoracoscopy 19 (23.8%) 44 (55.0%) 9 (11.3%) 26 (32.5%) Microbiology Sputum AFB smear (n=45) AFB culture (n=44) TB PCR (n=38) Overall (n=45) Pleural fluid AFB smear (n=79) AFB culture (n=79) TB PCR (n=64) Overall (n=79) Pleural tissue AFB smear (n=33) AFB culture (n=37) TB PCR (n=30) Overall (n=38) 2 (4.4%) 11 (25.0%) 6 (15.8%) 11 (24.4%) 0 (0.0%) 40 (50.6%) 12 (18.8%) 43 (54.4%) 1 (3.0%) 29 (78.4%) 5 (16.7%) 29 (76.3%) Data presented in number (percentage) and median (interquartile range); AFB: acid fast bacilli; TB: tuberculosis; PCR: polymerase chain reaction Table 2. Microbiological correlation with imaging findings in patients with TB pleuritis Chest radiograph abnormalities (CXR) CXR parenchymal abnormalities present No CXR parenchymal abnormalities p-value Sputum overall positive microbiology 9 (31.0%, 9/29) 2 (12.5%, 2/16) 0.166 Sputum AFB culture positive 9 (31.0%, 9/29) 2 (13.3%, 2/15) 0.199 Sputum TB PCR positive 5 (20.0%, 5/25) 1 (7.7%, 1/13) 0.324 Active CT parenchymal abnormalities* Active CT parenchymal abnormalities present No active CT parenchymal abnormalities Sputum overall positive microbiology 11 (33.3%, 11/33) 0 (0.0%, 0/5) 0.126 Sputum AFB culture positive 11 (34.4%, 11/32) 0 (0.0%, 0/5) 0.118 Sputum TB PCR positive 6 (22.2%, 6/27) 0 (0.0%, 0/5) 0.242 CT pleural abnormality CT pleural abnormality present (pleural nodularity/thickening) No CT pleural abnormality Pleural fluid overall positive microbiology 28 (51.9%, 28/54) 6 (50.0%, 6/12) 0.908 Pleural fluid AFB culture positive 26 (48.1%, 26/54) 6 (50.0%, 6/12) 0.908 Pleural fluid TB PCR positive 10 (21.7%, 10/46) 0 (0.0%, 0/11) 0.089 Pleural tissue overall positive microbiology 21 (80.8%, 21/26) 1 (25.0%, 1/4) 0.019 Pleural tissue AFB culture positive 21 (84.0%, 21/25) 1 (25.0%, 1/4) 0.010 Pleural tissue TB PCR positive 2 (8.7%, 2/23) 0 (0.0%, 0/2) 0.664 *Active CT parenchymal abnormalities defined as presence of consolidation, lung nodules, tree-in-bud or centrilobular nodularities or perifissural nodules Data presented in number (percentage); CT: computed tomography; CXR: chest radiograph; TB: tuberculosis; AFB: acid fast bacilli; PCR: polymerase chain reaction Additional Declarations No competing interests reported. Supplementary Files AppendixTBManuscript310725.docx Cite Share Download PDF Status: Published Journal Publication published 14 Nov, 2025 Read the published version in BMC Pulmonary Medicine → Version 1 posted Editorial decision: Revision requested 22 Sep, 2025 Reviews received at journal 19 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviews received at journal 17 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor assigned by journal 04 Sep, 2025 Editor invited by journal 03 Sep, 2025 Submission checks completed at journal 01 Sep, 2025 First submitted to journal 01 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7350627","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511331953,"identity":"0aa73ea0-a92a-4f62-aaed-d75a047db391","order_by":0,"name":"Si Ling Young","email":"data:image/png;base64,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","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Si","middleName":"Ling","lastName":"Young","suffix":""},{"id":511331957,"identity":"013b67a0-2213-44dc-b485-99ca467932dc","order_by":1,"name":"Brian Lee Wei Chua","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"Lee Wei","lastName":"Chua","suffix":""},{"id":511331960,"identity":"1bdbff28-3411-4c69-b01e-f16bcbb6563d","order_by":2,"name":"Qiao Li Tan","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qiao","middleName":"Li","lastName":"Tan","suffix":""},{"id":511331962,"identity":"21df5bdc-a6ec-44af-9124-a8c342b1d1c8","order_by":3,"name":"Carrie Kah Lai Leong","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Carrie","middleName":"Kah Lai","lastName":"Leong","suffix":""},{"id":511331964,"identity":"5d852efc-1b1d-49a5-b590-757d6928e2f4","order_by":4,"name":"Jane Jing Yi Wong","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"Jing Yi","lastName":"Wong","suffix":""},{"id":511331966,"identity":"1b622abf-4c34-4de6-bff1-948c63eb2592","order_by":5,"name":"Ivana Gilcrist Chiew Sian Phua","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ivana","middleName":"Gilcrist Chiew Sian","lastName":"Phua","suffix":""},{"id":511331967,"identity":"a20cb353-cc22-47b4-9fe6-afaf8b585138","order_by":6,"name":"Wen Ting Lim","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"Ting","lastName":"Lim","suffix":""},{"id":511331968,"identity":"1d4afa51-9e64-4447-819a-d378b09db5fc","order_by":7,"name":"Ken Junyang Goh","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ken","middleName":"Junyang","lastName":"Goh","suffix":""}],"badges":[],"createdAt":"2025-08-12 02:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7350627/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7350627/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12890-025-03995-1","type":"published","date":"2025-11-14T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91077278,"identity":"98a1c857-0d9e-4863-9142-44586c4d3621","added_by":"auto","created_at":"2025-09-11 11:14:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130300,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological characteristics of TB pleuritis\u003c/p\u003e\n\u003cp\u003eData presented in absolute numbers; CT: computed tomography; CXR: chest radiograph; TB: tuberculosis\u003c/p\u003e","description":"","filename":"Figure1RadiologicalcharacteristicsofTBpleuritis.png","url":"https://assets-eu.researchsquare.com/files/rs-7350627/v1/5b03f146a8113f72c6c6d2a3.png"},{"id":91077275,"identity":"613316ed-b583-4a18-bfc9-7abc8b82a525","added_by":"auto","created_at":"2025-09-11 11:14:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38600,"visible":true,"origin":"","legend":"\u003cp\u003eMicrobiological yield of respiratory and pleural specimens in TB pleuritis\u003c/p\u003e\n\u003cp\u003eData presented in percentages. Positive microbiology refers to either positive mycobacterial smear or culture, or TB PCR; Positive histology refers to necrotizing granulomatous inflammation; TB: tuberculosis\u003c/p\u003e","description":"","filename":"Figure2MicrobiologicalyieldinTBpleuritis.png","url":"https://assets-eu.researchsquare.com/files/rs-7350627/v1/c5dabcca8f45a9ac418a729e.png"},{"id":96105037,"identity":"192daed5-29aa-47d2-821b-5dbca7a49c32","added_by":"auto","created_at":"2025-11-17 16:07:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791560,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7350627/v1/4681aa2d-2bad-4af1-a51c-28014a748d3a.pdf"},{"id":91077277,"identity":"57951b1f-55e7-4a01-a4ca-6410d784a0c6","added_by":"auto","created_at":"2025-09-11 11:14:42","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":3512211,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTBManuscript310725.docx","url":"https://assets-eu.researchsquare.com/files/rs-7350627/v1/973efd1515538e7ffeb0a79f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pleural and Parenchymal Radiological Characteristics of Tuberculous Pleuritis and Correlation with Microbiological Diagnostic Yield","fulltext":[{"header":"Introduction and background","content":"\u003cp\u003eTuberculosis (TB) remains one of the leading infectious cause of death in the world over the past decade, second only to the COVID-19 pandemic between the years 2020 to 2022, with a significant healthcare burden worldwide\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Despite advances in the treatment of TB, the World Health Organization\u0026rsquo;s annual report on tuberculosis report an overall rise of TB incidence globally\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Of all cases of TB, tuberculous pleuritis (TB pleuritis) accounts for a significant proportion of the disease presentation, ranging from 2.2 to 31.4%\u003csup\u003e3,4\u003c/sup\u003e. It remains the second most common cause of extrapulmonary TB involvement, behind TB lymphadenitis, accounting for about 25% of these cases\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe exact pathophysiology of TB pleuritis remains unclear but is thought to be due to either primary or reactivated disease. The postulated mechanism in primary disease involves the TB bacilli entering the pleural space after rupture of a subpleural caseous foci\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This incites a delayed hypersensitivity reaction, resulting in an exudative process\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. TB pleuritis may also result from reactivation following latent TB infection, but these two entities are difficult to differentiate clinically as patients present similarly\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. TB pleuritis is hence thought to be closely associated with pulmonary TB given its postulated pathogenesis. However, the reported prevalence of concomitant pulmonary disease (based on the presence of radiographic parenchymal abnormalities) ranges widely from 8\u0026ndash;50%\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e. Even in studies that looked at the role of computed tomography (CT) imaging of the thorax in TB pleuritis, a similar wide range of prevalence of parenchymal disease, from 8\u0026ndash;86%\u003csup\u003e9,12,13\u003c/sup\u003e, was reported. Studies report a diagnostic yield of up to 50% with sputum acid-fast-bacilli (AFB) cultures in patients with TB pleuritis\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, however, it is unclear if these radiographic evidence of parenchymal disease correlate with the microbiological yield of respiratory specimens.\u003c/p\u003e\u003cp\u003eThe diagnostic yield of pleural fluid microbiology, both AFB smear and culture, and polymerase chain reaction (PCR), is also recognized to be poor. The yield of pleural fluid AFB smear is less than 10%, and AFB culture less than 30%\u003csup\u003e15\u003c/sup\u003e, but is higher in immunosuppressed patients with retroviral disease\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Aside from retroviral disease, it is uncertain if there are other factors that influence the yield of pleural microbiology, in particular with regards to pleural changes on imaging. The most commonly described CT pleural abnormality in TB pleuritis is that of a diffuse thickening of the pleura\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, of which Kim et al. reported in 32.6% of patients in their study of CT chest findings of TB pleuritis. Whether these pleural abnormalities have any correlation with the pleural fluid or tissue microbiology is unknown.\u003c/p\u003e\u003cp\u003eOur study hence aims to describe the CT parenchymal and pleural abnormalities in our patient cohort with TB pleuritis, and evaluate the microbiological yield of sputum, and pleural fluid and tissue respectively.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective analysis of patients with TB pleuritis diagnosed at a tertiary hospital in Singapore was performed. A definite diagnosis of TB pleuritis was made in patients who had pleural effusion and a positive sputum, pleural fluid or tissue microbiology for Mycobacterium Tuberculosis Complex (MTC), either in the form of AFB staining or culture or TB PCR, or tissue histology demonstrating necrotizing granulomatous inflammation. A presumptive diagnosis of TB pleuritis was made in patients who had a lymphocytic exudative pleural effusion with raised adenosine deaminase (ADA), which was defined as \u0026gt;\u0026thinsp;30 units/L, and a clinical and radiological response to anti-tuberculous treatment. All patients with a definite or presumptive diagnosis of TB pleuritis during January 2021 to December 2024 were included in this analysis. As this study was performed with anonymized data retrieved from a clinical audit, it was exempted from formal institutional review board approval.\u003c/p\u003e\u003cp\u003eData on patient baseline characteristics, radiological and microbiological results were collected. Radiological evaluation of chest radiographs and CT imaging of the thorax were performed by respiratory consultants (S.L.Y. and K.J.G.) with reference to the formal radiological reports by the hospital\u0026rsquo;s radiologists. The definitions of radiological abnormalities were adopted from the Fleischner glossary\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, namely for consolidation, ground glass opacities, nodules and masses. The effusion sizes as determined on chest radiograph are defined as follows: Small refers to effusions less than 25% of the hemithorax, moderate refers to effusions occupying 25\u0026ndash;50% of the hemithorax, large refers to effusions occupying 50\u0026ndash;75% of the hemithorax, and massive refers to effusions larger than 75% of the hemithorax or with evidence of mediastinal shift. Loculated effusions refer to effusions that show features of non-gravity dependence. The presence of parenchymal abnormalities on chest radiograph was determined based on the film performed after the effusion was mostly drained. Representative images are included in the appendix for further reference.\u003c/p\u003e\u003cp\u003eData analysis was performed on SPSS version 23. Descriptive statistics of the variables were expressed with in median with interquartile range (IQR), or numbers with percentage. Discrete variables were analysed with chi-square test (or Fischer\u0026rsquo;s exact test) and continuous variables were analysed with Mann-Whitney-U test. P values of less than 0.05 were considered to be statistically significant.\u003c/p\u003e\u003cp\u003eData from the study are not publicly available due to privacy restrictions. Requests for access should be directed to the corresponding author.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe included a total of eighty patients in our study analysis. The majority of the patients were male (78.8%), with a median age of 63 (interquartile range (IQR): 45\u0026ndash;73) years. Sixty-three patients (78.8%) were diagnosed with TB pleuritis based on a positive sputum or pleural (fluid or tissue) microbiology demonstrating MTC on culture. Five patients (6.3%) with no MTC isolated on culture were diagnosed based on the presence of necrotizing granulomatous inflammation on histology, and the remaining 12 patients (15.0%) had a presumptive diagnosis of TB pleuritis. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e describes the characteristics of our cohort of patients with TB pleuritis.\u003c/p\u003e\n\u003ch3\u003eChest radiograph features\u003c/h3\u003e\n\u003cp\u003eIn terms of chest radiographic characteristics, most effusions were right sided (67.5%) and moderate in size (41.3%). A significant proportion of patients also presented with large or massive effusions (18.8% and 12.5% respectively). Approximately half the cohort (53.8%) had parenchymal abnormalities noted on the chest radiograph. The majority of parenchymal abnormalities were located in the upper zone (67.4%, 29/43), and were consolidative in nature (67.4%, 29/43) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). A larger proportion of patients with small or moderate effusions had parenchymal abnormalities on chest radiograph, compared to patients with large or massive effusions (65.5% (36/55) vs 28.0% (7/25), p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\n\u003ch3\u003eSputum microbiology\u003c/h3\u003e\n\u003cp\u003eA total of forty-five patients had sputum specimens sent for microbiological assessment, of which forty-four patients had sputum AFB smear and culture performed, and thirty-eight patients had sputum TB PCR performed. Eleven patients (25.0%, 11/44) had an AFB culture result positive for MTC and six patients (15.8%, 6/38) had a positive TB PCR result. The yield of sputum culture for MTC was 31.0% (9/29) in patients with chest radiographic parenchymal abnormalities, and 13.3% (2/15) in patients with no parenchymal abnormalities on chest radiograph (p\u0026thinsp;=\u0026thinsp;0.199) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCT imaging features\u003c/h3\u003e\n\u003cp\u003eOf the whole cohort, sixty-seven patients had CT thorax performed as part of their workup. Forty-two patients (62.7%, 42/67) had diffuse pleural thickening observed on CT and twelve (17.9.0%, 12/67) had nodular or irregular pleural thickening seen. The most common parenchymal abnormality observed on CT was consolidation, with thirty patients (47.8%, 32/67) having ipsilateral consolidation, three (4.5%, 3/67) contralateral, and five (6.0%, 4/67) with bilateral consolidative change. The next most common was tree-in-bud or centrilobular nodularities (35.8%, 24/67), followed by non-calcified lung nodules with or without cavitation (32.8%, 22/67). Fifty-five patients (82.1%, 55/67) had parenchymal abnormalities that were suggestive of active pulmonary TB disease (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). This was defined as the presence of consolidation, lung nodules, tree-in-bud or centrilobular nodularities or perifissural nodules, with reference to the definitions used by Kim et al. in their study on pulmonary parenchymal tuberculosis in TB pleuritis\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOf these sixty-seven patients with CT imaging performed, thirty-eight patients had sputum sent for microbiological evaluation. Sputum microbiology seems to be positively correlated with the presence of active CT parenchymal abnormalities, though this was not a statistically significant result (33.3%, (11/33) vs 0.0% (0/5), p\u0026thinsp;=\u0026thinsp;0.126) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no statistically significant correlation between sputum microbiological positivity and parenchymal consolidation, tree-in-bud nodularities, or lung nodules individually.\u003c/p\u003e\n\u003ch3\u003ePleural fluid and tissue microbiology\u003c/h3\u003e\n\u003cp\u003eSeventy-nine and sixty-four patients had pleural fluid sent for AFB culture and TB PCR respectively. A total of thirty-eight patients had pleural biopsies performed, which were analysed for AFB smear and culture and/or histology. Thirty patients had pleural tissue TB PCR performed. The yield of pleural fluid and tissue AFB culture was 50.6% (40/79) and 78.4% (29/37) respectively. When comparing the yield of pleural fluid AFB culture in patients with and without CT pleural abnormalities, there was no statistically significant difference found (48.1% vs 50.0%, p\u0026thinsp;=\u0026thinsp;0.908). However, the yield of pleural tissue AFB culture was significantly higher in patients with CT pleural abnormalities, compared to patient with no pleural nodularity or thickening seen on CT (84.0% (21/29) vs 25.0% (1/4), p\u0026thinsp;=\u0026thinsp;0.010) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA total of seventy-nine patients had either sputum or pleural fluid samples sent for AFB smear and culture or TB PCR, of whom forty-nine (62.0%) patients had either at least one positive microbiology yield from either sputum or pleural fluid samples. Thirty-eight patients had pleural tissue analysed for either AFB smear and culture, histology or TB PCR, of whom thirty-five (92.1%) had a conclusive test for the diagnosis of TB pleuritis (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study describing the microbiological yield of sputum and pleural investigations in relation to CT thorax findings. While the diagnosis of TB pleuritis remains challenging, the increasing accessibility to CT scans provides valuable information that can further improve the diagnostic approach to patients with suspected TB pleuritis. In this study, in 67 patients with CT imaging performed, up to 80.6% and 82.1% were found to have pleural thickening and features of active pulmonary TB on CT imaging, respectively. Furthermore, we report an association between pleural abnormalities (thickening and nodularity) on CT with a higher microbiological yield for TB pleuritis following pleural biopsy. There also appears to be a trend towards a higher sputum microbiological yield in patients with lung parenchymal abnormalities seen on CT imaging.\u003c/p\u003e\u003cp\u003eThe prevalence of concomitant pulmonary TB in our cohort was 53.8%, based on the presence of chest radiographic parenchymal abnormalities. This is slightly higher than the majority of studies which report 17\u0026ndash;30%\u003csup\u003e17,20,21\u003c/sup\u003e coexistent pulmonary disease based on chest radiographs. This may be because our study assessed the parenchymal changes based on the radiographs that were performed after pleural interventions, hence reducing the possibility that the effusion was obscuring the parenchymal lesions. However, we recognize that there may be a small possibility that the parenchymal changes appreciated after a pleural intervention are related to re-expansion pulmonary edema, although this is rare\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and mitigated by controlled drainage post-intervention. Despite this, chest radiographic evidence of parenchymal disease still likely underestimates the actual prevalence of concomitant pulmonary TB, given that 82.1% of patients with CT in our study had changes suggestive of active pulmonary disease. This is similar to most existing studies reporting concomitant pulmonary TB on CT in 74\u0026ndash;86% of cases\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, and further corroborates the finding that CT is more sensitive in identifying parenchymal disease than chest radiographs in TB pleuritis\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eImportantly, there is suggestion of a higher yield of sputum microbiology in patients with CT parenchymal disease in our study. In our literature review, there was only one similar study performed by Lee et al., which was a prospective study evaluating the yield of bronchial aspirates (BA) via bronchoscopy in patients with suspected TB pleuritis\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. They found that there was positive BA microbiology in patients with pulmonary lesions on CT in 65% of cases, compared to 7% in those without. Our findings mirror this positive correlation, even in expectorated sputum.\u003c/p\u003e\u003cp\u003e31.0% of our patients with chest radiographic parenchymal abnormalities had positive sputum mycobacterial culture, compared to 12.5% of patients with no parenchymal changes. Although this was not a statistically significant difference, this mirrors existing studies describing a yield of 30\u0026ndash;33% in patients with chest radiographs demonstrating parenchymal involvement, as opposed to 9% in those without\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The study performed by Conde et al. stands out as having a significantly higher microbiological yield of 45\u0026ndash;55% using induced sputum, regardless of chest radiographic parenchymal disease\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This could be due to sputum induction being performed on all patients in the study, which has a reported yield of more than 60% in patients who are unable to expectorate sputum\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. To the best of our knowledge, there are no studies directly comparing the yields of sputum and induced sputum. The high induced sputum microbiological yield of 55% in patients without no parenchymal disease on chest radiograph reported by Conde et al. was also inconsistent with our study as well as other existing ones. We postulate that this could be due to two reasons: Firstly, that the sensitivity of a chest radiograph may be too low to adequately identify parenchymal changes secondary to pulmonary TB, and secondly, that there were more patients with moderate or large effusions (39.0%) in the group with no parenchymal changes compared to the group that had parenchymal disease (20%) in that study. Hence, these patients could have parenchymal disease, but were not appreciated given the larger effusions.\u003c/p\u003e\u003cp\u003eAnother key finding that our study reports is the positive correlation between CT pleural abnormalities and pleural tissue microbiology, but not with pleural fluid microbiology \u0026ndash; To our knowledge, this is a novel and unique finding that has not been previously reported in literature. The diagnostic yield of pleural tissue (defined as either positive mycobacterial or histological result) is high, ranging from 60 to over 90% depending on procedural tool used\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Although the demonstration of necrotizing granulomatous inflammation on pleural tissue is generally taken to be diagnostic of TB pleuritis, there are other possible pathogenic causes to consider based on patient demographics and disease endemicity\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, and mycobacterial culture is key to demonstrating the offending pathogen and obtaining culture sensitivities. Our findings suggest that in the presence of CT pleural abnormalities in a patient with suspected TB pleuritis, microbiological diagnosis to guide anti-tuberculous treatment is best approached by obtaining pleural tissue, as the pleural tissue AFB culture yield is much higher than other modalities. Pleural fluid alone does not predict microbiological yield, even in the presence of pleural disease on CT. This finding should also ideally be validated in larger cohorts, and may aid in further diagnostic algorithms in TB pleuritis.\u003c/p\u003e\u003cp\u003eThere are limitations to our study. This was a single center retrospective study with a relatively small population size, with only half the cohort having respiratory specimens sent for microbiology and four-fifths having had CT performed. This is most likely the reason why some of our results did not achieve statistical significance. However, the results of our study echo existing literature, and provide further insights into the various microbiological yields. We also did not conduct sputum induction or bronchoscopy for all patients, but we believe the use of expectorated sputum reflects real-life practice and limitations more accurately. This study also did not evaluate the use of thoracic ultrasound in TB pleuritis, which is increasingly being utilized to guide treatment decisions in undiagnosed pleural effusions\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Hence, larger prospective studies are needed to validate these results and incorporate thoracic ultrasound findings to diagnostic approaches for suspected TB pleuritis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA significant proportion of patients with TB pleuritis will have radiological features of active pulmonary TB on CT imaging. These CT abnormalities appear to be associated with a positive sputum culture for TB, but this needs to be evaluated in a larger study. Pleural tissue biopsy for culture and histology has by far the highest diagnostic yield for TB, and interestingly, pleural thickening on CT imaging was significantly associated with a positive pleural tissue AFB culture. Diagnostic imaging therefore holds promise in improving and personalising diagnostic pathways for patients with TB pleuritis, but well-designed prospective studies are needed to establish this.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was submitted to the institutional review board (SingHealth Centralised IRB 2025-0373). Informed consent for this analysis was waived and the study was exempted from formal review, as this was a retrospective analysis with anonymized data. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData availability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData from the study are not publicly available due to privacy restrictions. Requests for access should be directed to the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical trial number:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eS.L.Y. and K.J.G. conceived of the presented idea and devised the project. S.L.Y., B.L.W.C., Q.L.T., C.K.L. and K.J.G. processed the data and performed the analysis. S.L.Y., B.L.W.C., Q.L.T., C.K.L., J.J.Y.W., I.G.C.S.P., W.T.L. and K.J.G. contributed to the interpretation of the results. S.L.Y., B.L.W.C. and K.J.G. wrote the manuscript with input from all authors, and S.L.Y. designed the figures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Tuberculosis Report 2024: TB mortality. 2024. Published 2024. 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Exp Ther Med. 2018;16(3):2343\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3892/etm.2018.6471\u003c/span\u003e\u003cspan address=\"10.3892/etm.2018.6471\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Characteristics of patients with TB pleuritis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003en=80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eGender \u0026ndash; Male\u003c/p\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e63 (78.8%)\u003c/p\u003e\n \u003cp\u003e63 (IQR: 45 - 73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffusion CXR Characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLocation \u0026ndash; Right\u003c/p\u003e\n \u003cp\u003eSize\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Small\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Moderate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Large\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Massive\u003c/p\u003e\n \u003cp\u003eParenchymal abnormality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54 (67.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (27.5%)\u003c/p\u003e\n \u003cp\u003e33 (41.3%)\u003c/p\u003e\n \u003cp\u003e15 (18.8%)\u003c/p\u003e\n \u003cp\u003e10 (12.5%)\u003c/p\u003e\n \u003cp\u003e43 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffusion CT Characteristics (n=67)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePleural thickening\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Diffuse\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Nodular or irregular\u003c/p\u003e\n \u003cp\u003eLoculated effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42 (62.7%)\u003c/p\u003e\n \u003cp\u003e12 (17.9%)\u003c/p\u003e\n \u003cp\u003e53 (66.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePleural intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThoracentesis\u003c/p\u003e\n \u003cp\u003eChest drain\u003c/p\u003e\n \u003cp\u003eClosed or ultrasound guided pleural biopsy\u003c/p\u003e\n \u003cp\u003eThoracoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (23.8%)\u003c/p\u003e\n \u003cp\u003e44 (55.0%)\u003c/p\u003e\n \u003cp\u003e9 (11.3%)\u003c/p\u003e\n \u003cp\u003e26 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMicrobiology\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSputum\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB smear (n=45)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB culture (n=44)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;TB PCR (n=38)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Overall (n=45)\u003c/p\u003e\n \u003cp\u003ePleural fluid\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB smear (n=79)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB culture (n=79)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;TB PCR (n=64)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Overall (n=79)\u003c/p\u003e\n \u003cp\u003ePleural tissue\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB smear (n=33)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;AFB culture (n=37)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;TB PCR (n=30)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Overall (n=38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (4.4%)\u003c/p\u003e\n \u003cp\u003e11 (25.0%)\u003c/p\u003e\n \u003cp\u003e6 (15.8%)\u003c/p\u003e\n \u003cp\u003e11 (24.4%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e40 (50.6%)\u003c/p\u003e\n \u003cp\u003e12 (18.8%)\u003c/p\u003e\n \u003cp\u003e43 (54.4%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (3.0%)\u003c/p\u003e\n \u003cp\u003e29 (78.4%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e29 (76.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData presented in number (percentage) and median (interquartile range); AFB: acid fast bacilli; TB: tuberculosis; PCR: polymerase chain reaction\u003c/p\u003e\n\u003cp\u003eTable 2. Microbiological correlation with imaging findings in patients with TB pleuritis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eChest radiograph abnormalities (CXR)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eCXR parenchymal abnormalities present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eNo CXR parenchymal abnormalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum overall positive microbiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e9 (31.0%, 9/29)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e2 (12.5%, 2/16)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum AFB culture positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e9 (31.0%, 9/29)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e2 (13.3%, 2/15)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum TB PCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e5 (20.0%, 5/25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e1 (7.7%, 1/13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.324\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eActive CT parenchymal abnormalities*\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eActive CT parenchymal abnormalities present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eNo active CT parenchymal abnormalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum overall positive microbiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e11 (33.3%, 11/33)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e0 (0.0%, 0/5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum AFB culture positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e11 (34.4%, 11/32)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e0 (0.0%, 0/5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSputum TB PCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e6 (22.2%, 6/27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e0 (0.0%, 0/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 930px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCT pleural abnormality\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eCT pleural abnormality present (pleural nodularity/thickening)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eNo CT pleural abnormality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural fluid overall positive microbiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e28 (51.9%, 28/54)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e6 (50.0%, 6/12)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.908\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural fluid AFB culture positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e26 (48.1%, 26/54)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e6 (50.0%, 6/12)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.908\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural fluid TB PCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e10 (21.7%, 10/46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e0 (0.0%, 0/11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural tissue overall positive microbiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e21 (80.8%, 21/26)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e1 (25.0%, 1/4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural tissue AFB culture positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e21 (84.0%, 21/25)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e1 (25.0%, 1/4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003ePleural tissue TB PCR positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e2 (8.7%, 2/23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e0 (0.0%, 0/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e0.664\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Active CT parenchymal abnormalities defined as presence of consolidation, lung nodules, tree-in-bud or centrilobular nodularities or perifissural nodules\u003c/p\u003e\n\u003cp\u003eData presented in number (percentage); CT: computed tomography; CXR: chest radiograph; TB: tuberculosis; AFB: acid fast bacilli; PCR: polymerase chain reaction\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7350627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7350627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTuberculous (TB) pleuritis is a common extrapulmonary manifestation of the disease, with significant healthcare burden and morbidity. While there is increasing use of computed tomography (CT) scans for evaluation of patients with suspected TB pleuritis, little is known regarding the correlation of CT findings and respiratory and pleural specimen microbiological yield.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe performed a retrospective analysis of radiological features and microbiological yield from different diagnostic modalities in patients with TB pleuritis from January 2021 to December 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 80 patients were included in this study, with 78.8% male and a median age of 62 (interquartile range: 45-73 years). Approximately half (53.8%) of patients had parenchymal abnormalities on chest radiographs. CT imaging was performed in 67 patients, of whom 80.6% (54/67) had pleural thickening or nodularity, and 82.1% (55/67) had features of active pulmonary TB. M. Tuberculosis Complex (MTC) was isolated from sputum culture in 33.3% (11/33) of patients with CT features of active pulmonary TB, compared to 0% (0/5) in patients without. A higher proportion of patients with pleural thickening or nodularity on CT had MTC isolated from pleural biopsy samples, compared to patients without (84.0% vs 25.0%, p=0.010). There was no difference in the yield of pleural fluid TB culture between patients with and without pleural abnormalities on CT imaging (48.1% vs 50.0%, p=0.908).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCT features of active pulmonary disease or pleural thickening are common with TB pleuritis, and are useful to guide the diagnostic workup of patients with suspected TB pleuritis.\u003c/p\u003e","manuscriptTitle":"Pleural and Parenchymal Radiological Characteristics of Tuberculous Pleuritis and Correlation with Microbiological Diagnostic Yield","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:14:37","doi":"10.21203/rs.3.rs-7350627/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-22T07:26:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T16:58:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103839177539651849893545209910831285598","date":"2025-09-19T15:48:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115243534546145248212883519437947981218","date":"2025-09-17T15:49:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T11:00:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T20:30:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111958228325255307600010230732912060394","date":"2025-09-06T22:20:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184645803795163924538094574256041401402","date":"2025-09-05T17:51:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101009946607651359443124105752642209607","date":"2025-09-05T12:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256988502642095025066881047976972395073","date":"2025-09-05T00:28:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T22:17:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-04T22:04:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-03T06:21:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-02T02:40:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-09-02T02:37:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ffd74dd3-c9a9-4c79-a57c-a7acd58732c6","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:00:54+00:00","versionOfRecord":{"articleIdentity":"rs-7350627","link":"https://doi.org/10.1186/s12890-025-03995-1","journal":{"identity":"bmc-pulmonary-medicine","isVorOnly":false,"title":"BMC Pulmonary Medicine"},"publishedOn":"2025-11-14 15:57:05","publishedOnDateReadable":"November 14th, 2025"},"versionCreatedAt":"2025-09-11 11:14:37","video":"","vorDoi":"10.1186/s12890-025-03995-1","vorDoiUrl":"https://doi.org/10.1186/s12890-025-03995-1","workflowStages":[]},"version":"v1","identity":"rs-7350627","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7350627","identity":"rs-7350627","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}