Background The cause of epithelioid granulomatous inflammation varies widely depending on the affected organ, geographic region, and whether the granulomas morphologically contain necrosis. Compared with other organs, the etiological distribution and morphological patterns of pleural epithelioid granulomas have rarely been investigated. We evaluated the final etiologies and morphological patterns of pleural epithelioid granulomatous inflammation in a country with an intermediate tuberculosis (TB) prevalence. Methods The cases who had granulomatous pleural histology on pleural biopsy, retrospectively were reviewed and their final etiologies were identified. Patient with tuberculous pleurisy (TB-P) were classified into 2 groups according to the presence or absence of microbiological evidence: confirmed and probable TB-P. The clinical, blood, radiological, pleural fluid, and histological data were collected and compared between the confirmed and probable TB-P groups and between the confirmed TB-P and non- TB-P groups. Results Of 83 patients with pleural granulomas, 50 (60.2%) had confirmed TB-P and 29 (34.9%) had probable TB-P. Four patients (4.8%) with non-TB-P were diagnosed. With the exception of microbiological Results, there was no significant difference in patient characteristics and granuloma patterns between the confirmed TB-P and non-TB-P groups, or between patients with confirmed and probable TB-Ps. Additionally, anti-TB treatment outcomes were not significantly different between the confirmed and probable TB-P groups. Conclusions These findings suggest that most pleural granulomatous inflammation (95.2%) was attributable to TB-P in a TB-endemic area and that the granuloma patterns contributed little to the prediction of final diagnosis compared with other organs. However, the clinician should make active effort to find microbiological evidence for differentiation between TB-P and non-TB-P.