Bedside POCUS-guided Abrams pleural biopsy in the hands of respiratory physicians in a TB-endemic setting: diagnostic accuracy and safety

With an estimated global incidence of 360 cases per 100,000 annually, pleural effusion is a substantial health burden. In TB-endemic, resource-limited settings, timely diagnosis remains challenging. When pleural fluid analysis and clinico-radiologic evaluation are nondiagnostic, pleural biopsy is often required. Blind closed pleural biopsy remains widely used; point-of-care ultrasound (POCUS) guidance may improve diagnostic yield while maintaining a favorable safety profile. To evaluate the diagnostic performance, technical success, and safety of POCUS-guided Abrams pleural biopsy in adults with exudative pleural effusion. We conducted a prospective diagnostic study of consecutive adults with undiagnosed exudative pleural effusion who underwent POCUS-guided Abrams pleural biopsy at the Respiratory Medicine Department, Cho Ray Hospital (October 2019-May 2020). The primary outcomes were diagnostic performance for malignant pleural effusion (MPE) and tuberculous pleural effusion (TPE) against a composite reference standard. Among 117 patients, pleural tissue was successfully obtained in 116 (99.1%). Malignancy (59.8%) and tuberculosis (23.9%) were the leading etiologies. For MPE, POCUS-guided biopsy had a sensitivity of 61.4% and a specificity of 100%. For TPE, sensitivity was 57.1% and specificity was 100%. Sensitivity for malignancy was higher in patients with pleural thickening ≥ 3 mm than in those without significant thickening (80.8% vs. 50.0%; p = 0.01). The overall complication rate was 2.6%, comprising one pneumothorax (0.9%) and two vasovagal reactions (1.7%); no hemothorax, pleural infection, or intra-abdominal organ injury occurred. In this TB-endemic, resource-limited setting, POCUS-guided Abrams pleural biopsy achieved very high tissue yield and low complication rates, with moderate diagnostic sensitivity that improved substantially in the presence of pleural thickening. These findings support wider adoption of ultrasound-guided pleural biopsy as a safe, effective alternative to blind closed biopsy in similar settings.