A 70-year-old woman presented to the Emergency Department (ED) of our hospital with gradually worsening anorexia, and dyspnoea.
She was in her usual state up to 2 months prior when she developed dyspnoea and anorexia, leading to her first visit to the ED and hospitalization. During the initial evaluation, chest computed tomography (CT) was performed, which showed a large left pleural effusion and minimal right-sided pleural effusion, with no parenchymal abnormalities.
Thoracocentesis yielded a pleural exudate with a high leucocyte count (15.790/mcl) with 67.5% monocytes, and markedly elevated adenosine deaminase (ADA; 269.4 U/l) and LDH (3.590 IU/l) levels.
Pleural biopsy reported a non-specific inflammation of the pleural tissue without malignancy, granulomas or acid-alcohol resistant bacilli. Pleural fluid cultures were negative.
A presumptive diagnosis of pleural TB was made, based on elevated ADA levels, and empirical therapy was started with isoniazid, rifampicin, ethambutol and pyrazinamide. The patient reported an improvement in her general wellbeing and was discharged.
Over the following 2 months, the patient reported recurring progressing asthenia and anorexia. On the day of readmission, sudden-onset dyspnoea and general malaise developed, motivating a new admission to the ED.
Chest radiography showed an enlargement of the cardiac silhouette and a large-volume right pleural effusion. CT further showed a small left pleural effusion. Both CT and echocardiography showed a circumferential pericardial effusion with no further sonographic signs of tamponade risk. No other lesions besides pleural and pericardial effusions were found on the CT scan.
Blood tests yielded a normal haemogram, with elevated C-reactive protein (88.7 mg/dl) and LDH (335 IU/l) levels with no additional remarkable findings.
Pleural effusion analysis showed an elevated leucocyte count, ADA levels of 203.5 U/l and LDH elevation (1.535 IU/l).
Intravenous methylprednisolone was started at admission due to the pericardial effusion, resulting in rapid improvement of both the pericardial and pleural effusions.
Despite improvement, a small pleural effusion remained visible on chest radiography and a new thoracocentesis was performed during the hospitalization. This time, flow cytometry analysis was requested that identified the presence of anomalous lymphocytes, the immunophenotypic characteristics of which supported the diagnosis of diffuse large B cell lymphoma (DLBCL).
Empirical TB therapy was thus stopped, and the patient was referred to the Haematology department for treatment.
Due to the loss of muscle mass and autonomy, the patient was discharged to a rehabilitation facility to improve functional status before any treatment options were considered.