Pleural effusion: tuberculosis: steroids improved the chance of resolution.

Clinical bottom line (level 1b)

  1. Patients with pleural effusions who were at high risk for tuberculosis and had only diagnostic pleural taps were more likely to have complete resolution of the effusion if they took steroids and antituberculous medication rather than antituberculous medication alone (NNT = 3 at 8 weeks) .
Fleishman et al: Lancet 1960; 1: 199-201
Expires October 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: mining hospital, South Africa

39 patients (aged ?, ?% male) pleural effusion with no obvious cause

Excluded if
  • evidence of pulmonary tuberculosis or any pathology other than effusion


    • Note:
  • All patients had a positive tuberculin test, except for one.


    • Control Group: (n = 19, 19 analysed): streptomycin 1 g intramuscularly once daily and 200 mg isoniazid twice daily for two days, then 5 mg twice daily for the remaining eight weeks
    Experimental Group: (n = 20, 20 analysed): as above plus 10 mg prednisolone twice daily for two days, then 5 mg twice daily for the remaining eight weeks

    100% followed for 8 weeks
    Outcome notes:
    • failure : to achieve complete resolution of pleural effusion (on chest x-ray)

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    failure 8 weeks 15
    (79.0%)    		 8
    (40.0%)    		 49%
    (9% to 72%)    		 39.0%
    (10.7% to 67.2%)    		 3
    (1 to 9)

    Comments

    1. Uncertain diagnosis, but high incidence of tuberculosis in the population, and all the patients were young, and had no clear evidence of pneumonia, making tuberculosis the most likely cause.
    2. Patients had only 20 ml of fluid removed from the effusion for diagnostic purposes. Wyser et al were unable to show any benefit from steroids if the pleural effusions was drained completely at the start.

    Citation

    1. Fleishman SJ, Coetzee AM, Mindel S, et al: antituberculous therapy combined with adrenal steroids in the treatment of pleural effusions: a controlled therapeutic trial. Lancet 1960; 1: 199-201
    Search Terms: pleural effusion in Cochrane
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient pleural effusion and high risk for tuberculosis
    Intervention or Exposure steroids and antituberculous medication
    Comparison antituberculous medication alone
    Outcome treatment failure