Tuberculous polyserositis in endemic areas with an emphasis on empiric therapy

Abstract

Abstract Rationale: Polyserositis describes contemporaneous inflammation of multiple serous membranes accompanied by effusions in serous cavities. It has been associated with different aetiologies, including autoimmune diseases, endocrine diseases, neoplasia, drug-associated cases, and infectious diseases, such as tuberculosis. Patient concerns: We report the case of a 34-year-old woman who presented with abdominal swelling for 8 months, fatigability, and shortness of breath for 2 months. She denied a history of lower-limb swelling, orthopnea, paroxysmal nocturnal dyspnoea, or right upper quadrant pain. She had no history of cigarette smoking, prior treatment for tuberculosis, malignancy, or contact with someone known to have tuberculosis (TB). On examination, she had a weak pulse, muffled heart sounds, and ascites. Diagnosis: Polyserositis was suspected following visualization of fluid in the peritoneal, pleural, and pericardial cavities on imaging. Interventions: The patient underwent pericardiocentesis and ascitic taps. The patient also received spironolactone, prednisolone, and paracetamol. Despite repeated ascitic tapping and use of diuretics, fluid continued to accumulate until the initiation of empiric anti-TB drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol), as noted from the elevated levels of adenosine deaminase (pleural fluid-46.30U/L) and living in an endemic area for tuberculosis (Kenya). Outcomes: Three weeks after the initiation of anti-TB drugs, the ascites and pericardial and pleural effusions resolved. Two months after discharge, the patient showed marked improvement, with no residual fluid noted in the serous cavities on imaging. Lessons learnt: We report a case of extrapulmonary TB presenting with polyserositis (pericardial, pleural, and ascitic fluid) with elevated adenosine deaminase levels when the traditional Ziehl Neelsen staining yielded negative results. Good clinical judgment and more novel diagnostic tools are necessary to avoid unnecessary delays in initiating definitive management.