A CASE OF ISOLATED TB PLEURAL EFFUSION

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pleural tuberculosis accounts as one of the most common extrapulmonary manifestations of tuberculosis, second only to lymphadenopathy. Tuberculous pleural effusion (TPE) is the most common form of exudative effusion in the developing world. Isolated pleural involvement without parenchymal involvement is unusual. We report a patient with a lymphocytic exudative effusion that was revealed to be TPE only upon result of pleural acid-fast bacilli (AFB) culture, with the sputum and pleural AFB smears and pleural adenosine deaminase (ADA) being nondiagnostic. CASE PRESENTATION: A 64 year old Filipino male presented to the hospital with fever, chills, night sweats, and epigastric pain for 1 week. He was found to have a right pleural effusion with thickened pleural lining suspicious for empyema, measuring 8.8cm x 2.0cm x 8.2cm. He was placed in airborne precautions to rule out tuberculosis. A thoracentesis was performed that revealed a lymphocytic predominant (880 cells, 97% lymphocytes, 1% neutrophils) effusion. No organisms were seen on gram stain, bacterial culture, or AFB smear. Pleural fluid adenosine deaminase level was 37 U/L. After three induced sputum AFB smears resulted as negative, he was discharged at which point his symptoms had resolved. Patient was later seen in clinic a month after discharge at which point he was still asymptomatic. However, his pleural AFB cultures grew Mycobacterium tuberculosis, and he was started on anti-tuberculous therapy with rifampin, isoniazid, ethambutol, and pyrazinamide. DISCUSSION: This case resulted in a diagnosis of tuberculous pleural effusion despite the absence of pulmonary tuberculosis disease. Guidelines for the diagnosis of suspected pleural tuberculosis recommend the measurement of pleural ADA. Proposed pleural ADA cutoff values range from 10 U/L to 71U/L, with most studies using a level <40 U/L as the cutoff to exclude the diagnosis of TPE. Despite the highly lymphocytic predominant effusion, our patient's pleural fluid ADA level of 37 U/L led to a false reassurance of a non-tuberculosis diagnosis and a delay in diagnosis and treatment. In retrospect, a higher index of suspicion for TPE should have been maintained in this patient who presented with such a constellation of symptoms and radiographic evidence of an inflammatory effusion coupled with a suspicious pleural fluid analysis. Further diagnostics that could have been pursued to improve diagnostic sensitivity include needle biopsy or thoracoscopic pleural biopsy. Reference #1: Ciaran F. Keogh, Gordon T. Andrews, Sian D. Spacey, Kevin E. Forkheim, and Douglas A. Graeb. Neuroimaging Features of Heroin Inhalation Toxicity: “Chasing the Dragon” American Journal of Roentgenology 2003 180:3, 847-850 Reference #2: Blasel S, Hattingen E, Adelmann M, Nichtweiss M, Zanella F, Weidauer S. Toxic leukoencephalopathy after heroin abuse without heroin vapor inhalation: MR imaging and clinical features in three patients. Clin Neuroradiol. 2010;20(1):48-53. Reference #3: In Sub Yoo, MD, Sang Hak Lee, MD, Seung-Han Suk, MD, PhD. A Case of Fentanyl Intoxication and Delayed Hypoxic Leukoencephalopathy Caused by Incidental Use of Fentanyl Patch in a Healthy Elderly Man. J Neurocrit Care. 2015;8 (1):35-38. DISCLOSURES: No relevant relationships by Jasanjeet Jawanda, source=Web Response No relevant relationships by Antarpreet Kaur, source=Web Response No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Simrina Sabharwal, source=Web Response