---
title: "Diagnostic accuracy of cell-free DNA for tuberculous pleurisy: systematic review and meta-analysis"
id: "plos-one-15-utility-of-cell-free-dna-in-diagnosing-tuberculous-pleurisy-a-systematic-review"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-15-utility-of-cell-free-dna-in-diagnosing-tuberculous-pleurisy-a-systematic-review"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355485"
published_at: "2026-08-07T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Diagnostic accuracy of cell-free DNA for tuberculous pleurisy: systematic review and meta-analysis
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-15-utility-of-cell-free-dna-in-diagnosing-tuberculous-pleurisy-a-systematic-review
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355485)
- **Published At:** 2026-08-07T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Tuberculous pleurisy is the commonest extrapulmonary TB manifestation and is difficult to diagnose because pleural effusions are paucibacillary, reducing sensitivity of smear, culture, and NAATs. - The protocol proposes a systematic review and meta-analysis to assess the diagnostic performance of **cell-free DNA (cfDNA)** assays for tuberculous pleurisy. - cfDNA may include host-derived fragments and **Mycobacterium tuberculosis**–derived DNA; pathogen cfDNA could be more detectable in paucibacillary pleural fluid than intact bacilli. - Index tests include any cfDNA detection from pleural fluid, plasma, serum or other biofluids using technologies such as **qPCR**, **ddPCR**, isothermal amplification, or **mNGS** targeting mycobacterial sequences. - The reference comparator is a composite clinical reference standard incorporating microbiological, histopathological, and clinical response criteria. - Eligibility covers diagnostic accuracy studies (cross-sectional, cohort, case–control) that allow reconstruction of 2×2 contingency tables; studies without sufficient data will be excluded. - Searches will cover PubMed, Embase, Web of Science, Scopus, and Cochrane Library from inception to June 2027, with no initial language/date restrictions; manual reference screening is planned. - Dual independent screening, data extraction, and QUADAS-2 risk-of-bias assessment are specified; disagreements resolved by a third reviewer. - If ≥4 studies are available, a bivariate random-effects meta-analysis will pool **sensitivity** and **specificity**, and derive PLR, NLR, and DOR; hierarchical SROC curves, subgroup analyses and meta-regression will explore heterogeneity. - Certainty of evidence for pooled estimates will be graded using **GRADE**. - The protocol is registered on PROSPERO (CRD420261424501) and follows PRISMA-P and plans to report under PRISMA-DTA. - Timeline reported: literature search June 1–30, 2027; data extraction by Dec 31, 2027; final results expected by July 31, 2028. - Funding was provided by a Hangzhou biomedicine and health industry project; authors report no competing interests.
## Clinical Analysis & Structured Key Points
Utility of cell-free DNA in diagnosing tuberculous pleurisy: A systematic review and meta-analysis protocol | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Abstract Background Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis. Diagnosis remains challenging due to the paucibacillary nature of pleural effusions, leading to low sensitivity of conventional microbiological methods and frequent reliance on invasive biopsy. Cell-free DNA (cfDNA), comprising fragmented genetic material released from host cells and pathogens into biofluids, presents a promising minimally-invasive biomarker. This protocol outlines a systematic review and meta-analysis designed to evaluate the overall diagnostic accuracy of cfDNA for tuberculous pleurisy and to identify factors influencing its performance. Methods This protocol is prospectively registered with PROSPERO. We will systematically search PubMed, Embase, Web of Science, Scopus, The Cochrane Library from inception to June 2027. Diagnostic accuracy studies directly comparing cfDNA detection (in pleural fluid, plasma/serum) against a composite reference standard for tuberculous pleurisy (including microbiological, histological, or clinical diagnosis) will be included. Two reviewers will independently screen studies, extract data, and assess risk of bias using the QUADAS-2 tool. A bivariate random-effects meta-analysis will be performed to calculate pooled sensitivity, specificity, positive/negative likelihood ratios, and diagnostic odds ratios. A hierarchical summary receiver operating characteristic curve will be plotted. Subgroup analyses and meta-regression will explore sources of heterogeneity. The GRADE approach will be used to evaluate the certainty of evidence. Conclusion This review will provide pooled estimates of the diagnostic sensitivity and specificity of cfDNA for tuberculous pleurisy, evaluate its clinical utility, and identify key factors—such as sample type, detection technology, and pre-analytical procedures—associated with optimal performance. The findings will offer high-level evidence to guide clinical application and future research. Systematic review registration: PROSPERO Registration number: CRD420261424501 Citation: Shen Y, Du K, Ling Y, Yao L (2026) Utility of cell-free DNA in diagnosing tuberculous pleurisy: A systematic review and meta-analysis protocol. PLoS One 21(8): e0355485. https://doi.org/10.1371/journal.pone.0355485 Editor: Felix Bongomin, Gulu University, UGANDA Received: June 18, 2026; Accepted: July 22, 2026; Published: August 7, 2026 Copyright: © 2026 Shen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion. All supporting files are available from the OSF database: ( https://osf.io/xr6ua/overview?view_only=0af90cc15664446ab7237350204799d7) . Funding: This work was supported by Hangzhou Biomedicine and Health Industry Development Supporting Science and Technology Special Project. Yanqin Shen, 2023WJC162. The funder does not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction Tuberculous pleurisy, the most common extrapulmonary manifestation, poses a persistent diagnostic challenge [ 1 ]. Its pathogenesis involves a hypersensitivity reaction leading to lymphocyte-rich exudate and granuloma formation, which sequesters bacilli and creates a paucibacillary pleural environment [ 2 ]. This low bacterial burden undermines conventional diagnostics: culture is slow and insensitive (20–40%), smear is inadequate ( 50%), pre-specified subgroup analyses and random-effects meta-regression will be performed to explore potential sources. Covariates for investigation may include: sample type (pleural fluid vs. blood), cfDNA detection technology (PCR-based vs. mNGS), patient HIV status, rigor of the reference standard (microbiological/histological confirmation vs. clinical diagnosis), and study design. Sensitivity analysis will be performed using the “leave-one-out” method to examine the influence of individual studies on the pooled estimates. If any study is found to exert a disproportionate influence on the overall results or heterogeneity, it will be reported and discussed. For any subgroup or analysis with fewer than four studies, pooled estimates will be calculated using Meta-DiSc software (version 1.4) employing a fixed-effect model with exact binomial CIs, and results will be interpreted with caution. Given the complexities in interpreting funnel plot asymmetry in diagnostic accuracy meta-analysis, formal statistical testing for publication bias (e.g., Deeks’ funnel plot) will not be performed, but potential for publication bias will be discussed narratively [ 19 ]. Supporting information S1 File. Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist. https://doi.org/10.1371/journal.pone.0355485.s001 (DOCX) S2 File. Search strategies. https://doi.org/10.1371/journal.pone.0355485.s002 (DOCX) Acknowledgments We are grateful to the authors and research teams of the studies included in this meta‑analysis, particularly those who provided the detailed diagnostic accuracy data necessary for our quantitative synthesis. References 1. Shaw JA, Koegelenberg CFN. Pleural tuberculosis. Clinics in chest medicine. 2021;42(4):649–66. View Article Google Scholar 2. Pleşea IE, Pleşea EL, Pleşea RM, Şerbănescu MS, Olaru M, Nicolosu D, et al. Biological and cytological-morphological assessment of tuberculous pleural effusions. Rom J Morphol Embryol. 2024;65(4):693–712. pmid:39957032 View Article PubMed/NCBI Google Scholar 3. Huang F, Wang H, Qiao R, Peng Q, Zhao C, Miao L. Diagnostic accuracy and microbial profiles of tuberculous pleurisy: a comparative study of metagenomic next generation sequencing and GeneXpert Mycobacterium tuberculosis. Front Cell Infect Microbiol. 2023;13:1243441. pmid:38089819 View Article PubMed/NCBI Google Scholar 4. Chan KKP, Lee YCG. Tuberculous pleuritis: clinical presentations and diagnostic challenges. Curr Opin Pulm Med. 2024;30(3):210–6. pmid:38323466 View Article PubMed/NCBI Google Scholar 5. Huo Z-Y, Peng L. Is Xpert MTB/RIF appropriate for diagnosing tuberculous pleurisy with pleural fluid samples? A systematic review. BMC Infect Dis. 2018;18(1):284. pmid:29940951 View Article PubMed/NCBI Google Scholar 6. Yu W, Shen Y, Zhu P, Chen D. Head-to-head comparison of the efficacy of Xpert MTB/RIF Ultra and Xpert MTB/RIF for the diagnosis of tuberculous pleurisy: a systematic review and meta-analysis. Medicine (Baltimore). 2022;101(20):e29363. pmid:35608435 View Article PubMed/NCBI Google Scholar 7. Zhou X, Jiang P, Huan X, Li W, Chen Y, Gao H, et al. Ultrasound-guided versus thoracoscopic pleural biopsy for diagnosing tuberculous pleurisy following inconclusive thoracentesis: a randomized, controlled trial. Med Sci Monit. 2018;24:7238–48. pmid:30303950 View Article PubMed/NCBI Google Scholar 8. Che N, Yang X, Liu Z, Li K, Chen X. Rapid detection of cell-free mycobacterium tuberculosis dna in tuberculous pleural effusion. J Clin Microbiol. 2017;55(5):1526–32. pmid:28275073 View Article PubMed/NCBI Google Scholar 9. Wei Y-F, Yeh P-S, Wang P-H, Kuo Y-W, Shu C-C, Yan B-S. Using droplet digital polymerase chain reaction for cell-free DNA to diagnose tuberculous pleural effusion. Int J Infect Dis. 2026;168:108743. pmid:42055316 View Article PubMed/NCBI Google Scholar 10. Yang X, Che N, Duan H, Liu Z, Li K, Li H, et al. Cell-free Mycobacterium tuberculosis DNA test in pleural effusion for tuberculous pleurisy: a diagnostic accuracy study. Clin Microbiol Infect Diseases. 2020;26(8):1089. View Article Google Scholar 11. Xu F, Du W, Li C, Li Y, Li Z, Han W, et al. Evaluation of droplet digital polymerase chain reaction by detecting cell-free deoxyribonucleic acid in pleural effusion for the diagnosis of tuberculous pleurisy: a multicentre cohort study. Clin Microbiol Infect Diseases. 2024;30(9):1164–9. View Article Google Scholar 12. Du W-L, Liang J-Q, Yang X-T, Li C-J, Wang Q-F, Han W-G, et al. Accuracy of cell-free Mycobacterium tuberculosis DNA testing in pleural effusion for diagnosing tuberculous pleurisy: a multicenter cross-sectional study. Mil Med Res. 2024;11(1):60. pmid:39169415 View Article PubMed/NCBI Google Scholar 13. Sharma P, Gupta RK, Anthwal D, Dass M, Yadav R, Behera A, et al. Evaluation of Mycobacterium tuberculosis derived cell-free DNA using pleural fluid and paired plasma samples for the diagnosis of pleural tuberculosis. Tuberculosis (Edinb). 2023;142:102369. pmid:37536090 View Article PubMed/NCBI Google Scholar 14. Zhang S, Xu Y, Huang M, Pan Y, Shangguan J, Peng R, et al. Enhanced diagnosis of tuberculous pleurisy using a multiplex droplet digital PCR assay targeting circulating mycobacterial DNA. Thorax. 2026;81(8):738–48. pmid:41365631 View Article PubMed/NCBI Google Scholar 15. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 2015;4(1):1. View Article Google Scholar 16. McGrath TA, Moher D, McInnes MDF. Steps toward more complete reporting of systematic reviews of diagnostic test accuracy: Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy (PRISMA-DTA). Syst Rev. 2019;8(1):166. pmid:31296260 View Article PubMed/NCBI Google Scholar 17. Yao L, Bu C, Xiang L. The diagnostic accuracy of nanopore sequencing in Tuberculous Lymphadenitis: systematic review and meta-analysis protocol. PLoS One. 2025;20(6):e0325370. pmid:40493619 View Article PubMed/NCBI Google Scholar 18. Ling Y, Shen Y, Xu X, Yu G. Accuracy of next-generation sequencing for rapid diagnosis of tuberculous pleurisy: a protocol of systematic review and meta-analysis. PLoS One. 2025;20(2):e0319175. pmid:39999064 View Article PubMed/NCBI Google Scholar 19. McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, and the PRISMA-DTA Group, et al. Preferred reporting
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