A 32 year-old male presented with a 6 day history of an intermittent fever with chills and non-productive cough. He was previously well and did not report any haemoptysis, night sweats, weight loss or chest pain. His past medical and surgical histories were unremarkable. There was no history of exposure to ill contacts, institutionalization or cigarette smoking. Of note, the patient was a Chinese immigrant who spoke minimal English.
The patient's vital signs were stable on admission. Auscultation of his chest revealed decreased breath sounds in the right mid-to-lower zones, as well as diminished vocal fremitus in these regions. These regions were stony-dull to percussion, suggestive of an effusion. The remainder of his physical examination was unremarkable. Laboratory investigations revealed an elevated C-reactive protein (CRP) levels (220.2 mg/L) without a leukocytosis. Chest radiography demonstrated a large right pleural effusion. A chest tube was inserted (Fig. 1) under local anesthesia and drained 900mls of pleural fluid in the first 24 hours. Pleural fluid biochemical analysis revealed pleural fluid protein/serum protein ratio was 0.69 with a pleural fluid LDH of 3925 U/L, indicating an exudate. Sputum and pleural fluid cultures demonstrated no bacterial growth, but few pus cells and no malignant cells were identified. His tuberculin skin test was negative (0 mm, read at 72 hours). Sputum and pleural fluid smears were negative for acid-fast bacilli. He was also HIV-negative with no evidence of immunocompromise.
The patient was treated empirically with broad spectrum antibiotics (Ceftazidime) for 5 days without improvement. A computed tomography (CT) scan of the chest (Fig. 2) revealed a right pleural effusion with pockets of air and associated right lower lobe compressive atelectasis, suggestive of an early empyema. In an effort to attain a definitive diagnosis and treat his empyema, a video-assisted thoracoscopy (VATs) procedure with pleural biopsy and drainage was performed. Multiple adhesions and fibrinous exudates were noted intra-operatively. Five pleural biopsies were taken at varying sites. Post-operatively, due to a high degree of clinical suspicion he was commenced on anti-tuberculosis therapy (ATT). An immediate clinical response was noted as his fevers subsided, and his CRP decreased to normal levels. He recovered uneventfully and was discharged after 48 hours, pending outpatient clinic follow-up.
The pleural biopsy samples demonstrated active chronic granulomatous pleuritis with many Langerhans type giant cells highly suggestive of tuberculosis. The Ziehl-Neelsen stain for acid fast bacilli was negative. At our last outpatient visit, the patient had completed 6 months of ATT with complete disease resolution. He is clinically well and will continue follow-up in the Thoracic Medicine outpatient clinic.
Computed Tomography (CT) scan of the chest showing a right pleural effusion with air pockets and compressive right lower lobe atelectasis, suggestive of an early empyema.