A 14-year-old girl presented with 5-day history of continuous high-grade pyrexia on a background of a year's history of mild intermittent polyarticular arthralgia. The joints involved were the wrists, fingers, elbows, knees, ankles, and toes. There was no associated swelling, redness, or deformity. The joint pains were not associated with early morning stiffness. Her immunizations were up-to-date including BCG. She is the only child of Irish parents. Review of system revealed nondistressing chronic cough, anorexia, and occasional night sweats. History of TB contact was unknown. She had occasional malar rash which was thought to be flushing of cheeks.
Examination findings revealed a febrile girl in mild respiratory distress. She appeared pale, no digital clubbing or peripheral lymphadenopathy. Her vital signs were as follows: temperature 38.50 C, pulse rate 115 beats/minute, respiratory rate 32/minute, blood pressure 100/58 mmHg, and oxygen saturation 88% in room air. There was decreased chest expansion on the right. Air entry was diminished on the right upper and mid zones but absent at the base. Stony dull percussion on the right hemithorax was elicited.
Full blood count showed haemoglobin level 11 g/dL, white cell count 4000/mm3 (neutrophils 60%, lymphocytes 31%, and monocytes 9%), and platelet count 243,000/mm3. MCV was 71.7 fL, and MCH was 24 pg. Erythrocyte sedimentation rate (ESR) was 83 mm/hour, and C-reactive protein (CRP) was 54.8 mg/L. Lactate dehydrogenase (LDH) was 465 U/L, and urate was 401 micromol/L. The renal function and liver function tests were normal. Autoimmune screening showed that anti-nuclear antibody (ANA) was strong positive homogenous and anti-double-stranded DNA was >379 IU/ml. Other positive antibodies include extractable nuclear antibody, crithidia anti-double-stranded antibody, and anti-Ro and anti-La antibodies. IgM rheumatoid factor was <11.4 IU/mL. Serum ACE level was 47 U/L, and low C3 and C4 levels were at 0.73 and <0.08 g/L, respectively. Quantiferon TB1 and TB2 were 2.34  and 1.75 IU/ml, respectively. Pleural fluid biochemical analysis showed pH 7.25, protein 50 g/L, glucose 64 mg/dL, and LDH 256 U/L. There was pleural fluid lymphocytosis (85%) with no culture growth. Pleural fluid cytology showed loose aggregates of histiocytes and poorly formed granuloma (Figure 1). Bronchial lavage sample yielded no growth on culture. Chest radiography (Figure 2) demonstrated moderate to large volume right-sided pleural effusion. Contrast-enhanced computed tomography (CT) scan of thorax showed large right pleural effusion, bilateral axillary lymphadenopathy, and a bulky left hilum (Figure 3). The Mantoux test (before immunosuppressant therapy) was negative.
She was initially treated as a case of parapneumonic effusion. She received a 4-day course of antibiotics. Ultrasound-guided pigtail drain was inserted on her right chest, which drained approximately 2000 ml of serosanguinous fluid over 24 hours. Rheumatology team in view of SLE commenced her on a 3-day course of intravenous methylprednisolone and a 10-day course of tazobactam/piperacillin. She was continued on high-dose oral prednisolone. Other medications include hydroxychloroquine 200 mg once daily, mycotil mycophenolate (CellCept) 250 mg 12 hourly, and omeprazole 20 mg once daily. Following review of investigations by infectious disease team, she was started on quadruple anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol) and pyridoxine.
There was gradual but steady clinical improvement while on the SLE and TB treatments. Chest radiograph at 15 weeks of treatment showed near-complete resolution of effusion. She was on regular follow-up with the dietician, occupational therapist, and physiotherapist. Her inflammatory markers have returned to normal limits. She is currently enjoying school having been on treatment for 5 months.