A 42-year-old female patient, farmer by occupation, resident of Chamba district, presented to our outpatient department with chief complaints of fever for 2 months and right-sided chest pain for the same duration. The patient was apparently well before that when she presented with fever documented up to 102  Fahrenheit with evening rise in temperature and it was associated with night sweats but not associated with any chills and rigor or any rash or skin changes. Her right-sided chest pain was localized to infra-axillary region, nonradiating, sharp, nonexertional, and got aggravated on deep inspiration and coughing. There was no history of cough and shortness of breath. Ten years ago, she took treatment for lymph node (LN) TB but defaulted after 3 months of therapy. She never took any medication for diabetes and hypertension. There was no history suggestive of any contact with TB patient, or high-risk sexual behavior. Family history, menstrual history, and recent treatment history were unremarkable. On examination, the patient had pallor and mild dependent edema. Five LNs were palpable in the right cervical region superior and middle cervical region, the largest being 2.5 cm in diameter, matted, nontender, and not associated with any overlying skin changes not fixed to the underlying structure or skin. On respiratory system examination, the right infra-scapular and infra-axillary region were dull on percussion and breath sounds were decreased with shifting dullness suggestive of right-sided pleural effusion, which was confirmed by chest X-ray. About 5 mL of straw colored fluid was tapped and sent for investigation.
Investigations revealed the following: Hb 8.9 g/dL, total leukocyte count 4970 (neutrophils 76%, lymphocytes 15%, eosinophils 5%, basophils 3%, monocytes 1%), platelet 320,000, serum glutamic oxaloacetic transaminase 44, serum glutamic pyruvate transaminase 34, bilirubin total 0.8, albumin 3.9, alkaline phosphatase 128, urea 96, creatinine 1.9, Na 143, K 4.5, calcium 11.3 mg/dL, phosphorous 4.9, serum and urine electrophoresis was negative, intact parathyroid hormone 20 ng/L (8-51 pg/mL), arterial blood gas showed pH of 7.38, 25(OH) vitamin D 97 ng/mL (30-100 ng/mL), angiotensin converting enzyme level 10 U/L, urine routine and microscopy were normal, and urine for acid fast bacilli was negative. Urinary calcium level was higher than normal (U Ca/Cr = 32). Chloride level was 23 mmol/L. Ultrasonography KUB and noncontrast computed tomography KUB [Figure 1] were suggestive of medullary macro-calcification without any evidences of renal TB. Renal biopsy [Figure 2] was done showing interstitial deposition of calcium without any histological evidences for renal parenchymal TB. Intravenous pyelogram was done and it did not reveal any lesion suggestive of genitourinary TB. LN biopsy revealed caseating granulomatous change with Genexpert (CB-NAAT) positive. Pleural fluid was exudative, and lymphocyte was predominant (95%) with adenosine deaminase level of 67 ng/mL. Hence, a diagnosis of extrapulmonary TB was made.