Greetings. I’d like to ask advice from the community about a challenging case that I recently saw in clinic.
The patient is a 35 year old woman with pleural effusion of unclear etiology.
She was generally well until developing acute onset malaise, fever and chills, shortness of breath, and right-sided pleuritic chest pain over the course of a few days. Evaluation at a community hospital revealed a normal white blood cell count but her chest x-ray showed a moderate right-sided pleural effusion. A follow up chest CT showed right lower lobe enhancing opacity that was consistent with atelectasis as well as small areas of non-enhancing opacity in right hilar region that could represent consolidation. Elevation of the right hemidiaphragm with small to moderate R sided pleural effusion was also noted. There were otherwise no clear parenchymal lesions.
The patient underwent diagnostic and therapeutic thoracentesis. Results showed that she had a lymphocyte predominant exudative effusion. The pleural fluid pH and adenosine deaminase were elevated. The pleural fluid was AFB smear negative and routine, fungal and mycobacterial cultures were without growth. Cytology was negative for malignant cells.
The clinical picture was initially felt to be consistent with possible para-pneumonic effusion but TB could not be excluded. The patient was treated w/ levofloxacin x 10 days. She had a positive interferon gamma release assay a few weeks after her presentation. A repeat chest x-ray at that time showed interval resolution of effusion. Sputum testing was negative in three samples. Results from sputum mycobacterial culture, however, are pending. She was then referred to me for evaluation.
She overall feels improved since her thoracentesis. She is back to work but continues to have an occasional dry cough. Her appetite good but has lost 1-2 pounds compared to before onset of illness.
She was born in India but has been living in the US for over 10 years. She has never had a tuberculin skin test. She has no known TB exposures or risk factors for HIV.
She is well appearing with normal vital signs and a normal physical exam.
I’m curious as to what the community thinks are the possible etiologic causes of the patient’s syndrome. What features are consistent with TB pleurisy in your experience? What features are contradictory? In my mind, I think she has around a 50% chance of her illness being due to tuberculosis. Is that estimate too high? Too low? What other testing would you consider to try to make the diagnosis?
I recommended empiric treatment for a presumed tuberculous effusion but the patient refused because she didn’t want to believe that she had TB. How hard would you push her to start therapy? What would be the regimen that you would recommend? Does anyone have experience treating these patients with less than four drug therapy for less than six months? How should I think about her risk of contagion while trying to convince her to start therapy?
Please let me know your thoughts. I greatly appreciate any insights you can share.