Visual diagnosis of tuberculous pleuritis: diagnostic utility of miliary nodules on pleura and their correlation with tissue Xpert MTB/Rif assay and AFB culture

<b>Introduction:</b> The diagnosis of pleural tuberculosis is challenging due to its paucibacillary nature. Medical thoracoscopy remains the gold standard in diagnosing tuberculous pleuritis. White small nodules scattered on pleura (miliary nodules/sago seed) are the most common finding in tuberculosis. <b>Objectives:</b> To establish the diagnostic yield of thoracoscopic miliary appearance of pleura in tuberculosis and its correlation with histopathology, tissue AFB culture and tissue Xpert MTB/Rif assay. <b>Methods:</b> All consecutive patients with lymphocytic exudative pleural effusion, who fulfilled inclusion criteria of the study underwent medical thoracoscopy and pleural tissue was sent for histopathology, AFB culture and Xpert MTB/Rif assay. Chronic granulomatous inflammation on biopsy &amp; response to anti-tuberculous drugs was taken as diagnostic of tuberculosis. <b>Results:</b> A total of 249 patients were included in the study. Sago-like nodules visualized on thoracoscopy had a sensitivity of 55.36%, specificity of 88.89% and diagnostic accuracy of 66.27% for pleural tuberculosis. There is a strong association between the presence of sago-like nodules and detection of mycobacterium tuberculosis on Xpert MTB/Rif assay (p-value &lt;0.001). <b>Conclusion:</b> Miliary/sago seed nodules on pleura have a high diagnostic yield for tuberculous pleurisy. In high endemic countries patients with this finding on thoracoscopy can be commenced on anti-tuberculous treatment before histopathology or culture results are available. Pleural tissue Xpert assay is quick in diagnosing and confirming drug resistance.