Ultrasound-guided management of tuberculosis-related pleural effusion in a pediatric patient: A case report and literature review

Abstract

Tuberculosis (TB) remains a significant global health challenge, particularly within pediatric populations. This article reports the case of a 7-year-old female patient admitted with massive fibrinous pleural effusion secondary to TB, highlighting the key role of ultrasound in disease monitoring and therapeutic guidance. The patient presented with fever, cough, and abdominal pain. Imaging confirmed the presence of pleural effusion and lymphadenopathy. Serial ultrasound assessments demonstrated superior sensitivity compared to CT in characterizing the pleural effusion, leading to the initiation of intrapleural urokinase therapy under ultrasound guidance. The treatment resulted in the successful dissolution of fibrin septations and marked clinical improvement. The discussion explores the diagnostic advantages of ultrasound in pediatric TB, its effectiveness in monitoring therapeutic response, and the utility of localized fibrinolytic therapy. This case highlights the value of ultrasound as a cost-effective, noninvasive, radiation-free tool in the management of pediatric TB, advocating for its increased integration into routine pediatric care.

Introduction

Tuberculosis stands as one of the most prevalent infectious diseases [1] across all age groups, persisting as a significant cause of mortality and morbidity worldwide, with pulmonary involvement emerging as the primary site of Mycobacterium tuberculosis infection [2]. The pediatric demographic notably contributes to the global burden of tuberculosis infections, with an estimated 7.5 million children becoming infected annually, and approximately 1 million children exhibiting symptomatic manifestations of active tuberculosis disease [3]. Diagnostic approaches commonly employed for tuberculosis infection include the tuberculin skin test, which entails the intradermal injection of a tuberculin protein mixture and subsequent measurement of induration resulting from delayed hypersensitivity reactions after 48–72 hours, alongside Interferon Gamma Release Assays (IGRAs) [4], which detect interferon gamma release in blood following exposure to TB-specific antigens ESAT-6 and CFP-10 [5]. Radiological investigations, notably chest X-ray and CT scans, serve as primary modalities for tuberculosis diagnosis and therapeutic monitoring [6], demonstrating heightened sensitivity in detecting hilar and mediastinal lymphadenopathy, parenchymal, and pleural disease, as well as associated complications [7]. The use of ultrasound in evaluating tuberculosis-related complications, such as characterizing pleural effusion and guiding drainage procedures, is gaining prominence [8]. A growing body of evidence supports its alternative use in mediastinal lymph node detection and monitoring response to antituberculosis therapy [9].

This article presents a case report of a pediatric patient admitted with massive fibrinous pleural effusion resulting from Mycobacterium tuberculosis infection, elucidating the utility and efficacy of ultrasound monitoring in fibrin debridement through intrapleural urokinase instillation.

Case presentation

A 7-year-old female patient presented with a 7-day history of fever, productive cough, and right hypochondrial abdominal pain radiating ipsilaterally. Born at 38 weeks of gestation with a birth weight of 2900 g, the patient had an unremarkable medical history, with no known exposure to tuberculosis. On admission, she was alert and responsive, with vital signs indicating a temperature of 38.8°C, heart rate of 122 beats per minute, blood pressure of 100/60 mmHg, and respiratory rate of 48 breaths per minute. Subcostal chest retractions were observed. Physical examination revealed palpable and visibly enlarged bilateral lymph nodes in the latero-cervical and supraclavicular regions. Thoracic auscultation identified globally reduced vesicular breath sounds over the right hemithorax and diminished breath sounds with fine crackles at the left lung base. There was no evidence of cyanosis or hepatosplenomegaly, and the abdomen was slightly distended but nontender upon palpation. Arterial blood gas analysis showed a partial pressure of oxygen (PaO2) of 68 mmHg, partial pressure of carbon dioxide (PaCO2) of 48 mmHg, pH 7.30, bicarbonate (HCO3) concentration of 27 mEq/L, and oxygen saturation of 90% on room air (FiO2 21%). A thoracic CT scan revealed a large right pleural effusion extending from the base to the apex, with areas of atelectasis in the posterior basal, lateral, and middle lung fields of the right lung. Additionally, pericentimetric lymphadenopathy was noted in the right paratracheal, subcarinal, and right hilar regions, as well as enlarged bilateral supraclavicular and latero-cervical lymph nodes. Positive results from both the Mantoux test and the T-SPOT.TB assay confirmed tuberculosis, prompting the initiation of appropriate anti-tuberculosis therapy with rifampicin and isoniazid, alongside drainage of the pleural effusion. Serial thoracic ultrasounds were performed to assess the progression of the effusion. These revealed a large anechoic pleural effusion in the right mid-basal region, with loculated fibrin septations and compressive atelectasis of the right lung parenchyma, findings that were more detailed than those provided by CT. Ultrasound monitoring suggested a complicated effusion with a suboptimal therapeutic response, leading to the decision to administer intracavitary urokinase under ultrasound guidance (Fig. 1).

Fig. 1.

Longitudinal thoracic ultrasound in the parasternal region focused on the right lung of a pediatric patient with tuberculosis. The scan demonstrates a large loculated pleural effusion, visualized as a hypoechoic area with scattered hyperechoic foci, and a prominent empyema characterized by an irregular, jagged pleural line, appearing as a ribbon-like hyperechoic structure traversing the effusion.

Within 3 days, the fibrin septations had dissolved, the effusion had decreased, and the patient showed clinical improvement (Fig. 2).

Fig. 2.

Longitudinal ultrasound scan of the parasternal region, 36 hours after urokinase administration. The image clearly shows the dissolution of the fibrin network, indicating a positive therapeutic response.

By day 6, normal A-line reverberation artifacts were observed on ultrasound, signifying successful treatment. Subsequent ultrasound examinations (Fig. 3) demonstrated ongoing resolution of the effusion and progressive re-aeration of the lung, with full restoration of normal lung aeration patterns by approximately 30 days post-urokinase administration (Fig. 4).

Fig. 3.

Ultrasound examination 15 days postintracavitary urokinase therapy demonstrates a significant reduction in pleural effusion. Notably, there is clear pleural line approximation, accompanied by the reappearance of the typical A-line pattern, indicating normalization of thoracic ultrasound findings.

Fig. 4.

CT scan at diagnosis (A) and after Treatment (B). Arrows indicate pleural effusion.

Discussion

Ultrasound can effectively detect several pediatric pulmonary conditions [10], including tuberculosis and its complications [11]. In the evaluation of tuberculosis, ultrasound has demonstrated slightly lower sensitivity compared to CT, but superior accuracy when compared to chest X-ray. When ultrasound is combined with X-ray, its sensitivity becomes comparable to that of chest CT. Giannelli et al. conducted a comparative study among the 3 imaging modalities—ultrasound, CT, and chest X-ray—in a cohort of 82 patients with tuberculosis, reporting a sensitivity of 96.3% for lung ultrasound, 95.1% for radiography, and 100% for chest CT [12]. The study identified nodules (95%), micronodules (82%), consolidations with air bronchograms (72%), and cavitations (33%) as findings with high diagnostic sensitivity detectable by ultrasound. In addition, ultrasound may serve as a valuable tool to evaluate the response to local treatments in pleural effusions. Park et al. assessed the efficacy of transcatheter instillation of urokinase in conjunction with ultrasound and radiographic investigations in a cohort of 16 patients with loculated pleural effusion [13]. The study found that transcatheter instillation of urokinase was effective in treating localized effusions, although it was less effective in patients with honeycombing patterns on lung ultrasound or pleural thickness greater than 5 mm. Overall, ultrasound has demonstrated its utility in studying pleural effusions both before and after therapy, as well as in guiding the selection of local therapeutic interventions. A meta-analysis by Jing W. and colleagues, which included 39 randomized controlled trials, concluded that clinical outcomes in patients with tuberculous pleural effusion were superior when fibrinolytic agents were combined with antituberculosis therapy [14]. The meta-analysis highlighted benefits such as significant reduction in pleural effusion and pleural thickness, rapid improvement in lung function, and shorter effusion absorption times. Ultrasound has also proven effective in studying lung pathology in tuberculosis patients. Agostinis et al. conducted ultrasound assessments in 60 patients with confirmed tuberculosis, identifying subpleural hypoechoic nodules associated with pulmonary consolidations, pleural effusions, a miliary pattern, and cavitations [15]. Similarly, Moretó-Planas L. et al. performed a cross-sectional study using focused point-of-care ultrasound (POCUS) in a cohort of children aged 6 months to 15 years. The study reported POCUS-positive findings in 93% of cases, demonstrating a high sensitivity for tuberculosis detection and efficacy in monitoring disease resolution [16]. To the best of our knowledge, the present report represents the only documented pediatric case of ultrasound being used in the diagnosis of tuberculosis-related complications. It provides a valuable example of the efficacy of local urokinase therapy as an adjuvant treatment and supports ultrasound as an economical, radiation-free, and reliable method for monitoring disease recovery.

Conclusion

Tuberculosis remains a prevalent disease, particularly challenging to diagnose in pediatric populations due to subtle and nonspecific symptoms. Conventional radiological diagnostics present limitations in terms of cost, reproducibility, and radiation exposure. Treating associated complications, such as pleural effusion, poses additional challenges, impacting lung function and necessitating prolonged recovery periods. This case report exemplifies ultrasound's utility in studying and managing tuberculosis complications, particularly loculated pleural effusion, alongside the effectiveness of intracavitary urokinase administration, underscored by serial ultrasound monitoring, offering a paradigmatic pediatric study model and advocating for ultrasound's broader clinical integration in tuberculosis management.

Patient consent

A written, informed consent to describe the case has been acquired.