Chest Infections: Chest Infections II |

Extra Pulmonary TB Presentation in a Non-HIV 37-Year-Old Female FREE TO VIEW

Rosa Arancibia, MD; Khushboo Chokshi, MD; Kimberly Foley, MD; Joseph Gorga, MD; Daniel Buchnea, MD
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Downstate Medical Center, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A115. doi:10.1016/j.chest.2016.02.120
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SESSION TITLE: Chest Infections II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: TB pleural effusion is the second most common form of Extra Pulmonary TB, only less frequent than lymph node TB especially in non HIV Pts. Tuberculous pleural effusion accounts for approximately 5 percent of disease due to Mycobacterium tuberculosis. Most TB pleural effusions manifest as an acute illness, with approximately one third of patients being symptomatic for < 1 week and two thirds for < 1 month.

CASE PRESENTATION: Pt is 37 y/o f who presented with fevers and dyspnea and chest-x-ray showed a large left sided pleural effusion. Pt had thoracocenthesis, drained 1.5L colorless fluid, and cell count: 1540 WBC, 88% lymphocytes, 4% mono, LDH: 352, glucose: 134, protein: 4.7 cholesterol: 119. After 2 hours, pleural fluid re-accumulated and lung did not expand. Pig tail placement with minimal drainage. Repeated chest CT showed atelectatic lung with thick rind and remaining pleural fluid. ADA level: 6.5. PPD was positive 20mm by 15mm. PT had a left sided VATS showing thickened and inflamed pleura rind with loculated fluid collections. Pleural biopsy showed necrotizing granuloma.

DISCUSSION: TB pleural effusions are lymphocytic-rich exudative. It affects no more than two thirds of the hemithorax. High ADA concentration is a highly sensitive diagnostic. The most sensitive criterion based on pleural biopsy was the observation of granulomas 50 to 97 percent, and biopsy culture is positive 40 to 80 percent1. Low mean age of the patients and frequency of associated pulmonary lesions, suggests that tuberculous pleural effusion is a primary form of tuberculosis. Our case is unique because her chest CT did not show any parenchymal lesions nor radiologically features of active TB. Her pleural effusion was large occupying the entire left hemithorax. Typically, histologic examination from the pleural biopsy may demonstrate granulomatous inflammation, caseation necrosis, or AFB. In our Pt, pleural biopsy showed necrotizing granuloma. Since her pleural effusion was large and later progressed to a loculated effusion, it indicates that this was becoming a chronic active infection in the pleural space. This may explain the unexpandable lung after initial thoracocenthesis2. Our PT had no parenchymal involvement so pleural disease may have developed via hematogenous spread following primary infection mainly due to a delayed hypersensitivity reaction3 due entry of mycobacterial antigens into pleura.

CONCLUSIONS: This case demonstrates TB pleuritis should rest on clinical rather than microbiologic or histologic criteria alone. Presumptive therapy is warranted for patients with lymphocytic exudate and a positive PPD, even in the absence of definitive diagnosis since there is a risk of developing pulmonary or extrapulmonary TB within five years.

Reference #1: Diagnosis and treatment of pleural effusions, Gopi A, Mandahavan SM, Sharma SK, chest 2007

Reference #2: Tuberculous empyema, Sahn SA, Iseman MD, Semin Respir Infect 1999

Reference #3: Tuberculous Pleural effusion, Seibert AF, Haynes J Jr, Chest 1991

DISCLOSURE: The following authors have nothing to disclose: Rosa Arancibia, Khushboo Chokshi, Kimberly Foley, Joseph Gorga, Daniel Buchnea

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