An 84-year-old Asian man was admitted to hospital for dyspnea and was found to have a large, recurrent right-sided pleural effusion. This was the third time our patient presented with an effusion since the initiation of rifampin, isoniazid, pyrazinamide and ethambutol (RIPE) therapy for presumed extrapulmonary TB. Nine months prior to this presentation, our patient underwent a screening colonoscopy with a biopsy that reportedly yielded a single granulomatous, acid-fast stain-positive, but TB culture-negative lesion. No anti-TB treatment was initiated at that time. The purportedly acid-fast stain-positive specimen could not be located subsequently for re-review. A repeat colonoscopy with biopsy at six months demonstrated no granulomas or other evidence of TB. There was no radiographic evidence of pulmonary TB and interval sputum cultures were negative, as was a serum QuantiFERON-TB Gold test. Nevertheless, our patient was started on RIPE combination therapy.
Four weeks after the initiation of this regimen (two months prior to the episode described in this report), our patient complained of dyspnea, cough and weakness. He was admitted to hospital with the initial right-sided pleural effusion presentation (Figure ). Thoracocentesis yielded exudative, culture- and stain-negative pleural fluid (Table ). Our patient was given a presumptive diagnosis of a paradoxical tuberculous effusion and discharged on a tapering course of systemic glucocorticosteroids while he continued on RIPE therapy. Two months later, he was re-admitted with a similar clinical picture. A further liter of exudative fluid was removed by repeat thoracocentesis (Figure and Table ).
Figure 1 Chest X-ray images. (A) Large pleural effusion in his right lung field found on the first admission. (B) Large pleural effusion in his right lung field on the second admission. (C) Pleural effusion in his right lung field on the current admission, two (more ...)
Laboratory values for the pleural fluid collected from the three effusions our patient manifested.
Two weeks later, a re-accumulated pleural effusion led to the admission we report (Figure ). Our patient underwent a video-assisted thoracoscopic surgical biopsy. The pleural fluid again demonstrated a lymphocytosis with benign cytology and an adenosine deaminase assay yielded a value of 23.8 units per liter (Table ). Multiple pleural biopsies demonstrated inflammation without any well-formed granulomata. All cultures of pleural fluid and biopsies were TB negative. Our patient's pleural fluid, which had not been tested serologically on previous thorocenteses, manifested a low complement with a total complement activity (CH50) of 10, but was antinuclear antibody (ANA) negative. The serum ANA titer, however, was elevated to 1:160 with a speckled pattern, while a serum antihistone assay was negative. The isoniazid was discontinued, although rifampin and ethambutol were continued to complete a nine-month course as recommended by the infectious disease subspecialty consultants. There have been no further pleural effusions over two years of follow-up.