A 33-year-old native of the Democratic Republic of the Congo with history of occupational TB exposure in Rwanda six years prior to presentation initially presented to the emergency department complaining of a five day history of exertional dyspnea, midepigastric pain, high fevers, (Tmax 101.9 F) and fatigue. The patient reported that he was a healthcare worker in a TB clinic and delivered anti-tuberculous medications to patients with active pulmonary TB. He reported a positive Quantiferon Gold TB screening in 2014 with negative chest x-ray. He also denied ever receiving treatment for latent tuberculosis. At no point did the patient ever complain of cough, night sweats, or weight loss.
He was admitted to the COVID-19 unit due to elevated clinical suspicion for COVID-19 pneumonia. Computed tomography (CT) chest without contrast demonstrated evidence of diffuse ground-glass opacities, peri-pancreatic inflammation, and a moderate right-sided pleural effusion (Fig. 1). A pancreatic pseudocyst of 33 mm x 30 mm x 23 mm was noted and subsequently confirmed on MRI-liver with and without contrast. Lipase was non-elevated at 216 U/L. He underwent right sided thoracentesis with 350 cc fluid drained, with total serum protein 6.8 g/dL, pleural fluid protein 5.7 g/ dL, serum LDH 129 U/L, pleural fluid LDH 315 U/L, indicating an exudative process by Light's criteria. Cytology, acid fast bacilli (AFB) smear and culture were sent for evaluation and were subsequently negative after 6 weeks. Serum antigen HIV testing was non-reactive. With resolution of symptoms, the patient was subsequently discharged with diagnoses of right sided pleural effusion induced by pancreatitis with incidental finding of a pancreatic cyst and was instructed to follow up outpatient with pulmonology and gastroenterology.
The patient was evaluated by outpatient pulmonology two months later and was found to have recurrent right pleural effusion, requiring repeat thoracentesis that again demonstrated cytology negative exudative process (serum protein 6.8 g/dL, pleural fluid protein 5.4 g/dL, serum LDH140U/L, pleural fluid LDH252 U/ L). Pleural adenosine deaminase (ADA) was sent and resulted at 7.6 U/L (reference range 0-9.4 U/L). One month after outpatient thoracentesis, he was again admitted to the hospital due to worsening dyspnea and was found to have a recurrent large right pleural effusion requiring repeat thoracentesis. SARS-CoV-2 Polymerase Chain Reaction (PCR) testing returned positive and the patient was admitted to the COVID-19 medical floor. Oral dexamethasone 6 mg daily was initiated. 1650 cc green-yellow pleural fluid was aspirated and sent for fluid analysis with similar findings of an exudative process by Light's criteria as above. Additional analyses performed included flow cytometry that did not demonstrate immunophenotypic evidence of a monotypic B-cell or aberrant T-cell population. Pleural fluid studies including fluid differential, ADA, cholesterol, amylase, triglycerides, and glucose, did not display abnormalities. Post-thoracentesis chest x-ray demonstrated a significant amount of residual pleural fluid, warranting consultation with cardiothoracic (CT) surgery for consideration of video-assisted thoracoscopic surgery (VATS) with biopsy and pleurodesis to be scheduled as an outpatient. The patient remained hemodynamically stable without the need for supplemental oxygen and was discharged home after 2 days. He completed a 7-day course of dexamethasone. Pre-operative 2D echocardiogram demonstrated a left ventricular ejection fraction of 56% without diastolic or valvular abnormalities.
Unfortunately, the patient's VATS with pleurodesis was canceled as the patient did not follow up with CT surgery.
One month later the patient returned to the emergency department complaining of recurrent left-sided pleuritic chest pain and high fevers at home. On arrival he had a fever of 102.4 F with otherwise stable hemodynamics and no oxygen requirement. CT angiogram with PE protocol was again performed demonstrating a large left pleural effusion (Fig. 2). Previous imaging of the pancreatic pseudocyst measuring 33 x 30 x 23 mm showed a decrease in size compared to previous exam and was now measured as 25 x 19 x 17 mm. Pulmonology and cardiothoracic surgery were consulted and left VATS with pleurectomy, pleurodesis, pleural and diaphragm biopsy and cultures with evacuation of left pleural effusion was performed on hospital day two. Intraoperatively, green-tinted serous pleural fluid with diffuse studding of vesicles papules and plaques on the parietal pleura, visceral pleura, and diaphragm were noted (Fig. 3). In regards to previously visualized pancreatic cyst, gastroenterology and surgical oncology were consulted, however opted to manage conservatively with outpatient surveillance MRI due to decreasing size of the collection. Pathology of pleural, diaphragmatic and pleural peel tissue demonstrated organizing fibrous tissue with fibrinous exudate as well as areas of granulomatous inflammation. There was evidence of central areas of necrosis in multiple granulomas. Special stains for acid-fast and fungal organisms were negative. Pleural fluid ADA was performed with ARUP Laboratories and was interpreted as within normal limits at 18 U/L (reference range 0-30 U/L). Multiple AFB cultures and smears from pleural fluid, chest wall tissue, and pleural tissue were collected and sent for analysis.
Given granulomatous changes on pathology, the patient was transferred to a negative pressure room with airborne precautions and serum QuantiFERON Gold testing was ordered due to elevated suspicion for pleural tuberculosis. QuantiFERON Tb Gold Plus resulted positive. Infectious disease was consulted and recommended initiation of treatment for pleural TB with a four-drug regimen including rifampin 600 mg daily, isoniazid 300 mg daily, pyrazinamide 1500 mg daily, ethambutol 1200 mg daily and supplemental pyridoxine 50 mg daily. The State Department of Health was notified of findings and assumed care of the patient with initiation of contact tracing and further testing as appropriate. AFB cultures and smears from pleural fluid, chest wall tissue and pleural tissue resulted negative for acid fast bacilli after six weeks.
Following initiation of TB medications and VATS surgery, the patient has not had a recurrence of dyspnea or pleural effusions. He remains symptom free 1 year from initiation and completion of antimicrobial therapy.