Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A tuberculose está entre as dez principais causas de morte no mundo e o Brasil é um dos 22 países que concentram 80% da carga mundial da doença. A apresentação pleural, objeto central do presente estudo, é a mais comum forma extrapulmonar em indivíduos HIV soronegativos e sempre aparece como diagnóstico diferencial a ser considerado nos portadores de derrames pleurais no País. O diagnóstico de tuberculose pleural fundamenta-se principalmente na identificação do agente Mycobacterium tuberculosis no exame direto ou cultura do líquido pleural ou dos fragmentos de tecido pleural, assim como na presença de granuloma na análise histopatológica dos mesmos. O objetivo principal deste trabalho é conhecer a qualidade dos diagnósticos e o perfil epidemiológico dos portadores de tuberculose pleural no estado de Roraima visando embasar tecnicamente o fomento e aplicação de políticas públicas para o enfrentamento da doença em questão. O presente estudo foi desenhado como uma pesquisa quali-quantitativa do tipo corte transversal para avaliar os critérios diagnósticos utilizados e seus determinantes da apresentação pleural da doença no estado de Roraima, localizado na Região Norte do Brasil, dentro dos limites da Amazônia Legal, local que possui extensa diversidade sociocultural e ambiental. Trata-se de um estudo observacional, retrospectivo e descritivo baseado na revisão de dados secundários do SINAN, incluindo todos os casos notificados como portadores de tuberculose pleural de 2005 a 2013 no referido Estado. Dos 1.395 casos de tuberculose notificados no período, 8,3% foram da apresentação pleural, totalizando 38,9% das formas extrapulmonares na amostra. A taxa de incidência desta apresentação não acompanhou a tendência decrescente da forma pulmonar da doença no período. A prevalência de diagnósticos de qualidade encontrada foi de 28,5% (IC95%: 20,4 a 37,6%), e, em análise univariada nenhuma variável explicativa dentre as características demográficas e clínicas possíveis de serem apuradas no banco de dados tiveram impacto significativo na qualidade dos diagnósticos. A principal conclusão do estudo remete à necessidade de uma política de referenciamento específica a nível estadual no intuito de facilitar o acesso aos métodos diagnósticos preconizados pelo Programa Nacional de Controle da Tuberculose disponíveis no sistema de saúde. / Tuberculosis is among the ten main causes of death in the world and Brazil is one of 22 countries that account for 80 % of the global burden of disease. Pleural presentation, the main object of this study, is the most common extrapulmonary TB form in HIV-seronegative individuals and always appears as a differential diagnosis to be considered in patients with pleural effusions. The main objective was to know the quality of diagnoses and the epidemiological profile of patients with pleural tuberculosis in the state of Roraima aiming to offer a technical foundation to public policies destined to fight the disease. The diagnosis of pleural tuberculosis is based primarily on the identification of Mycobacterium tuberculosis on direct examination or culture of pleural fluid or pleural tissue fragment, as well as in the presence of granuloma on histopathological analysis of the tissue sample. The present study was designed as a qualitative and quantitative transversal research to evaluate the diagnostic criteria being used and the determinants of pleural disease presentation in the state of Roraima, located in northern Brazil, within the limits of the Amazon, and with extensive socio-cultural and environmental diversity. This is an observational, retrospective and descriptive study based on a review of secondary SINAN data, including all cases of pleural tuberculosis reported from 2005 to 2013. Of 1.395 reported cases of tuberculosis in the period, 8.3% were of pleural presentation, totaling 38.9% of extrapulmonary cases in the sample. The incidence rate of this presentation did not follow the downward trend of pulmonary tuberculosis in the period. The prevalence of quality diagnosis was found to be 28.5 % (95% CI: 20.4 to 37.6 %), and in a univariate analysis, no variable among the possible clinical and demographic characteristics searched in the data basis had significant impact in the quality of the diagnosis. The main conclusion of the study indicates the need for a specific referral policy at a state level in order to facilitate access to diagnostic methods recommended by the National Tuberculosis Control Programme available in the health system.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Objectives: Diagnosis of pleural tuberculosis (PT) is still a challenge, particularly in resource-constrained settings. Alternative diagnostic tools are needed. We aimed at evaluating the utility of Clinical Prediction Rules (CPRs) for diagnosis of pleural tuberculosis in Peru. Methods: We identified CPRs for diagnosis of PT through a structured literature search. CPRs using high-complexity tests, as defined by the FDA, were excluded. We applied the identified CPRs to patients with pleural exudates attending two third-level hospitals in Lima, Peru, a setting with high incidence of tuberculosis. Besides pleural fluid analysis, patients underwent closed pleural biopsy for reaching a final diagnosis through combining microbiological and histopathological criteria. We evaluated the performance of the CPRs against this composite reference standard using classic indicators of diagnostic test validity. Results: We found 15 eligible CPRs, of which 12 could be validated. Most included ADA, age, lymphocyte proportion and protein in pleural fluid as predictive findings. A total of 259 patients were included for their validation, of which 176 (67%) had PT and 50 (19%) malignant pleural effusion. The overall accuracy of the CPRs varied from 41% to 86%. Two had a positive likelihood ratio (LR) above 10, but none a negative LR below 0.1. ADA alone at a cut-off of ≥40 IU attained 87% diagnostic accuracy and had a positive LR of 6.6 and a negative LR of 0.2. Conclusion: Many CPRs for PT are available. In addition to ADA alone, none of them contributes significantly to diagnosis of PT.

Made available in DSpace on 2014-07-29T15:30:34Z (GMT). No. of bitstreams: 1 Dissertacao Loanda Carvalho S Limongi.pdf: 1004813 bytes, checksum: 09f423fef50cc45223e734df788a0c39 (MD5) Previous issue date: 2009-12-18 / Pleural tuberculosis (TBP) has often spontaneous resolution, even without treatment. However, the lack of proper diagnosis and treatment can lead to the occurrence of pulmonary and/or extra-pulmonary tuberculosis in 65% of the cases, in the five years subsequent. The objective of this study was to evaluate the effectiveness of the recombinant Hsp-X antigen (rHsp-X) in an enzyme immunoassay for determining the presence of TBP in patients with pleural effusion. For this study we used 132 samples of serum and pleural fluid (PF) from patients with pleural effusion. Of these, 97 samples were from TBP patients and 35 patients with diseases other than tuberculosis (NTBP) (28 patients with metastatic cancer, 1 patient with congestive heart failure, 2 patients whit liver failure, 1 patient with systemic lupus erythematosus and 3 patients with parapneumonic effusion). The IgM levels of PF were higher in patients with PTB than NTBP, the sensitivity and specificity of the ELISA for the PF was 42% and 83%, respectively. Testing for IgG from the serum and the PF against the recombinant antigen Hsp-X were not effective in discriminating TB patients from other diseases, the sensitivity was found to be 13% and 16% using serum and LP, respectively, with the same specificity of 83%. TBP patients presented higher levels of IgA specific for the rHSP-X than NTBP, the IgA ELISA using PF presented better sensitivity (65%) than using serum (39%), while the IgA ELISA for both types of samples presented the same specificity (83%). In conclusion, the recognition of Mycobacterium tuberculosis rHsp-X by IgA antibodies from the PF of patients with TBP reveals its possible role in the development of a diagnostic test for additional cases of TBP. Further studies must be conducted to confirm this hypothesis. / A tuberculose pleural (TBP) frequentemente tem resolução espontânea, mesmo sem tratamento. No entanto, a ausência de diagnóstico e tratamento pode levar, nos cinco anos subseqüentes, à ocorrência de tuberculose pulmonar e/ ou extrapulmonar em 65% dos casos. O objetivo deste estudo foi avaliar a eficácia da utilização do antígeno Hsp-X em um ensaio imunoenzimático para determinação da presença de TBP em indivíduos com derrame pleural. Para o estudo foram utilizadas 132 amostras de soro e líquido pleural (LP) de pacientes com derrame pleural. Destas, 97 amostras eram de pacientes TBP e 35 de pacientes com outras doenças não tuberculosas (NTBP) (28 pacientes por câncer metastático, 1 pacientes por insuficiência cardíaca congestiva, 2 paciente por insuficiência hepática, 1 paciente por lúpus eritematoso sistêmico e 3 pacientes por derrames parapneumônicos). Os níveis de IgM do LP foram mais elevados nos pacientes com TBP do que os NTBP, a sensibilidade do ELISA para do LP de 42%, para a especificidade de 83%. Os ensaios para pesquisa de IgG, do soro e do LP, contra o antígeno Hsp-X não foram eficazes em discriminar pacientes com TBP de outras doenças, a sensibilidade encontrada foi de 13% e 16%, utilizando o soro e o LP, respectivamente, para a mesma especificidade de 83%. A densidade óptica dos ensaios para pesquisa de IgA, específicos para o antígeno rHsp-X, foi mais elevada nos pacientes TBP do que os NTBP, o ELISA com a IgA do LP foi melhor que o ELISA do soro, a sensibilidade foi de 65% e 39%, respectivamente, para a mesma especificidade de 83%. Concluímos que o reconhecimento de Hsp-X recombinante de Mycobacterium tuberculosis pelos anticorpos IgA do LP de pacientes com TBP indicam que esse antígeno poderá ser utilizado para o desenvolvimento de um teste de diagnóstico complementar para casos de TBP. Estudos adicionais precisam ser realizados para confirmar tal hipótese.