Our patient is a 42-year-old female who had presented in Ethiopia with vague symptoms of a few months of fatigue, weakness, and unintentional weight loss of 3-4 kg. She was subsequently diagnosed with renal failure, requiring hemodialysis. The etiology of her renal failure was unclear. She went to India to see if she could obtain another explanation for her symptoms and continued hemodialysis there. Due to a lack of improvement in her symptoms, she came to the United States for different treatment options.
She presented initially to an American hospital with dyspnea and volume overload. She underwent a chest X-ray for dyspnea (Figure 1) which was largely unremarkable. A computed tomography (CT) angiography of her chest was negative for pulmonary embolism, but notable for non-specific lymphadenopathy and small right-sided pleural effusion. She also underwent CT imaging of her abdomen and pelvis which noted multiple small renal cysts bilaterally, which were too small to characterize. Her symptoms were thought to be secondary to ESRD, and she was advised to continue outpatient hemodialysis.
She presented again to the hospital two-and-a-half months later with progressive dyspnea on exertion and right-sided chest pain. The patient denied any hemoptysis, nausea, vomiting, diarrhea, or prior exposure to tuberculosis. Patient had a negative cardiac workup. She underwent another CT angiography of her chest which showed no pulmonary embolism, but now showed loculated right pleural effusion (Figure 2(a)), subcarinal and right hilar adenopathy (Figure 2(b)). Thoracentesis was performed. Analysis of the pleural fluid revealed it was an exudative effusion (pH 7.8, white blood cells 1083 cells/mm3, 24% lymphocytes, <25% polymorphonuclear cells, glucose 84 mg/dL, and Lactate dehydrogenase 270 U/L) with moderately elevated adenosine deaminase (ADA, 57.6 U/L) level. Fungal culture and gram stain of pleural fluid did not reveal any fungal or bacterial organisms. She produced two sputum samples which were both negative for acid fast bacilli smear and culture. Patient was also found to have persistent hypercalcemia (11.7-12.8 mg/dL), elevated 1,25-dihydroxyvitamin D (131 pg/mL), normal parathyroid hormone level (53.8 pg/mL), and surprisingly elevated PTHrP (52 pg/mL). At this point, there was concern for malignancy such as lymphoma, but the pleural fluid did not show any malignant cells and peripheral flow cytometry did not show any abnormal T or B cells. Endobronchial ultrasound was performed with biopsy of lymph node showing necrotic tissue, with insufficient cells to send for lymphoma stains. She was also found to have a positive quantiferon, but negative acid fast stain of bronchoalveolar lavage and sputum samples. She underwent a right pleural biopsy as well, with results pending when patient was discharged from the hospital. Patient was hemodialyzed, treated with 9-day course of piperacillin-tazobactam for fevers of unknown origin, and advised to follow-up in clinic.
She presented a week later with similar complaints and worsening tachycardia during her hemodialysis sessions. Chest radiograph showed moderate right pleural effusion with consolidation throughout right lung base. Serum leukemia/lymphoma panel was negative. Patient underwent mediastinoscopy with excisional lymph node biopsy as her previous fine needle aspiration was non-diagnostic. The biopsy of the lymph node showed necrotizing granulomas (Figure 3). Eventually, the acid fast stain of the pleural biopsy sample resulted and showed growth of mycobacterium tuberculosis. Patient was started on medications that were weight-based (patient's weight 48.1 kg), which included oral rifampin 600 mg daily, isoniazid 300 mg daily, pyrazinamide 1500 mg three times a week after dialysis, and ethambutol 1200 mg three times a week after dialysis. Drug susceptibility testing indicated that the mycobacteria was sensitive to the medication regimen. One week after starting therapy, patient's PTHrP decreased to 35 pg/mL and normalization of serum calcium concentration (9.9 mg/dL) occurred. Patient's fevers, tachycardia, and chest pain improved on these antibiotics.