Diagnostic and Therapeutic Impact of Medical Thoracoscopy in Tuberculosis Pleuritis

Background: Tuberculous pleuritis (TBP) presents a diagnostic challenge due to its paucibacillary nature. The gold standard for diagnosing TBP requires the identification of Mycobacterium tuberculosis in tissue culture and evidence of granulomatous inflammation in pleural specimens. We aimed to determine the diagnostic yield and accuracy of medical thoracoscopy, as well as its utility in early diagnosis and treatment in a low-prevalence region. Methods: This is a retrospective study of patients with suspected TBP between 2020 and 2024 in a large hospital system in New York City. A subgroup of patients underwent medical thoracoscopy with pleural biopsy for histopathological and microbiological evaluation, and their results were compared to those of a cohort initiated on RIPE treatment without pleural tissue analysis. Results: Of 129 patients included, medical thoracoscopy was performed in 46 cases, with 31 (67.4%) diagnosed with TBP, 4 (8.7%) with nontuberculous pleuritis, and 11 (23.9%) with chronic idiopathic pleuritis. The diagnostic yield for tuberculosis was 67.4% in a low-prevalent region, with an overall accuracy of 89.1%. Out of 83 patients who were initiated on RIPE therapy based on clinical suspicion of TBP, 18 (21.7%) had no microbiological evidence of tuberculosis. The time to RIPE initiation was shorter in the medical thoracoscopy group (3.0 [IQR, 1.0–5.0] days vs. 5.0 [IQR, 3.0–13.0] days, P = 0.006). Conclusions: Medical thoracoscopy offers high accuracy and a diagnostic yield in a low-prevalent region, facilitating early diagnosis and leading to more timely and appropriate treatment initiation. Diagnosis of TBP in areas of low prevalence may help reduce drug resistance and inappropriate treatment regimens.