Clinical course management and outcomes of tubercular empyema. A prospective study in a high tuberculosis area of Pakistan

Mycobacterium tuberculosis (MTB) rarely causes purulent empyema compared to other bacterial pathogens. This study aimed to determine the clinical course, radiological findings, pleural fluid characteristics, surgical interventions, complications, and outcomes of tubercular empyema. This cohort study was conducted in the Department of Pulmonology at Ayub Teaching Hospital, Abbottabad, Pakistan, from July 2023 to January 20, 2026. Different types of empyema were compared using normally distributed continuous variables (age, total leukocyte count, and protein levels) through one-way analysis of variance. Homogeneity of variances was assessed using Levene's test. Tukey's post hoc test was applied when variances were equal, while the Games-Howell test was used when this assumption was violated. Associations between clinical variables and empyema types were further evaluated using Binary logistic regression. Results were reported as odds ratios with 95% confidence intervals. A p-value <0.05 was considered statistically significant. A total of 38 patients were included over 2.7 years. Of these, 53% (n=20) were male and 47% (n=18) were female. Most patients (78%) were from Khyber Pakhtunkhwa, 11% were from other provinces (Islamabad and Karachi), and 11% were from Afghanistan. The mean age was 46±18 years (range: 14-75 years). Nearly all male patients were engaged in high-risk occupations such as mining, hotel labor, driving, or teaching. Tubercular empyema was observed in 58% (n=22) of patients, and bacterial empyema in 42% (n=16). The most common presenting symptoms were cough, fever, and shortness of breath (67%). Chest pain was present in 50% of patients with bacterial empyema. Thick, calcified pleura (67%) was the most common radiological feature in tubercular empyema, followed by hilar lymphadenopathy. Pleural fluid analysis showed positivity rates of 33% for acid-fast bacilli, 44% for tuberculosis culture, and 56% for GeneXpert. Additionally, 33% of tubercular empyema cases were diagnosed via Abram's pleural biopsy. Tubercular empyema demonstrates distinct clinical, radiological, and pleural fluid characteristics. Although associated with significant complications, outcomes can be improved with timely diagnosis and appropriate management. The neutrophilic effusion doesn't exclude a workup for pleural tuberculosis.