State of the art: practical evaluation and management of tuberculous pleural effusion

PURPOSE OF REVIEW: Tuberculous pleuritis (TBP) is one of the most common causes of new-onset pleural effusion, particularly in tuberculosis-endemic regions. This review discusses recent advances in the diagnosis and practical management of TBP, with an emphasis on integrating biomarkers, molecular tests, imaging and pleural tissue sampling into context-specific workflows. RECENT FINDINGS: The clinical and radiological features of TBP are highly heterogeneous. Certain imaging patterns can help distinguish TBP from other benign or malignant effusions, but they are not fully diagnostic. The diagnostic accuracy of conventional pleural fluid microbiology is limited by the paucibacillary nature of TBP, prompting greater use of pleural biopsy and medical thoracoscopy, which improve microbiological and histological yield. Advanced nucleic acid amplification tests (NAATs), including Xpert MTB/RIF Ultra and emerging sequencing-based assays, have progressively increased sensitivity on pleural fluid, but wider clinical adoption is constrained by incomplete external validation, cost and limited availability. Adenosine deaminase remains the most commonly used pleural fluid biomarker. However, its optimal diagnostic thresholds are highly context-specific and may shift with changing tuberculosis incidence and age distribution. Practical diagnostic workflows now favour flexible use of biomarkers, imaging and pleural tissue sampling to maximize confirmation of TB involvement, while recognizing that patients with probable TBP treated empirically require close follow-up to document treatment response and exclude alternative diseases. Management remains centred on standard anti-tuberculosis regimens, with drainage and other interventions reserved for symptom relief or loculated disease and routine corticosteroid use is not supported by high-quality evidence. SUMMARY: Despite advances in pleural fluid biomarkers, molecular diagnostics and pleural procedures, TBP remains challenging to diagnose reliably. Clinicians should maintain a high index of suspicion for TBP in undiagnosed exudative effusions, especially in endemic regions and adopt locally adapted workflows that combine clinical assessment, biomarkers, NAATs and early pleural tissue sampling when needed.