A 31-year-old white man from Caracas, Venezuela presented in the emergency room complaining of daily evening fever, night sweats, pleuritic chest pain and shortness of breath for the previous 2 weeks. Up until 2-weeks before, over 10 days, he had received a daily dose of intramuscular nandrolone (Deca-Durabolin  50 mg), but was not taking any other medication. A chest X-ray showed a pleural effusion occupying 30% of the left hemi-thorax. His physical examination, blood count and serum biochemistry were otherwise unremarkable. A thoracentesis obtained clear fluid, exudative by lactate dehydrogenase (LDH) and protein levels, (310 UI/l and 4,8 gr/dl respectively) normal pH (7,46) and predominantly eosinophils (30%) in the leukocyte differential count (2500 cell per cubic milliliter) and 50% lymphocytes and 20% neutrophils. No peripheral blood eosinophilia was found. AFB staining of the pleural fluid was negative and the ADA level was normal (21 UI/L). The patient gave no history of TB contact and a TST was negative (0 mm). Culture of the pleural fluid for bacteria on blood agar and for mycobacteria on Lowenstein Jensen and Stonebrink medium was negative. A parasitic infection was suspected but serial stool examinations were negative for parasites. No definitive diagnosis was made, but malignant pleural effusion was suspected.
After thoracentesis the patient felt better and did not return to the hospital until 4-months later, when he returned to the emergency room with similar pleuritic symptoms, fever and night sweats. Additionally, he had a nonproductive cough and had lost more than 5 kilograms in weight since the previous visit. Examination of the lungs revealed decreased breath sound in the lower left hemi-thorax, but the rest of the physical examination was normal. A chest X-ray again showed the left sided pleural effusion, slightly smaller than on the previous study. A second thoracentesis obtained turbid fluid, pH 7 41, 3100 cells per cubic millimeter, 90% mononuclear and 3% eosinophils, 5,4 gr/dl proteins and 242 UI/dl LDH. Glucose, amylase levels, hematological parameters, renal and hepatic serum tests were normal. The effusion/serum ratio for proteins and LDH were 0 77 and 0 83 respectively. The ADA on the pleural fluid was elevated (51 U/L) and suggestive of tuberculosis, and the TST was positive (20 mm). Ziehl-Neelsen staining for AFB was negative both on induced sputum and pleural liquid. A pleural biopsy showed a chronic pleurisy with multiple granulomas with central necrosis, compatible with pleural TB and a culture of the pleural tissue was positive for M. tuberculosis after 4 weeks. The patient's symptoms disappeared after starting treatment with anti-tuberculosis drugs, and the chest X-ray showed resolution of the effusion 4 weeks later, turning completely normal.