A 34-year-old man presented with high-grade fever with chills and rigors and left-sided pleuritic type chest pain associated with a lump in the anterior chest wall. He was a patient with stage 5 chronic kidney disease and was on regular hemodialysis through an arteriovenous fistula during the past one year. He was awaiting kidney transplantation.
On examination, he was febrile with a temperature of 38.7 C. There were multiple enlarged tender axillary lymph nodes on the left side. The lymph nodes were around 0.5 cm and mobile and deep seated. He was dyspneic, breath sounds were reduced in the left lower zone of the lung with few crepitations. There was a tender lump (5 x 5 cm) on the left anterior chest wall. Other system examinations were found to be normal.
Approximately four months prior to the aforedescribed admission, he was investigated previously for fever, poor appetite, and loss of weight lasting for one-month duration. Clinical examination had revealed crepitation in the left lower lung base. Investigations done during that previous admission had revealed normal full blood count, erythrocyte sedimentation rate (ESR) of 93 mm in 1st hour, and C-reactive protein at 23 mg/dl. Chest X-ray had shown evidence of left lower upper and lower lobe patchy opacities. He had been treated with IV co-amoxiclav 1.2 g three times daily empirically. As a further evaluation, contrast-enhanced computed tomography (CECT) of the chest was performed, which had revealed poorly defined small nodules and tree-in-bud opacities in the left lower lobe with focal consolidation in the apical segment of the left upper lobe in keeping with chronic lung infection. A small well-defined enhancing subpleural nodule with speculated margin in the posterior segment of the left lobe and few hilar and pretracheal enlarged lymph nodes were also seen. The Mantoux test had been 20 mm. Sputum direct smear for acid-fast bacilli (AFB) and culture had been negative. A tentative diagnosis of tuberculous infection had been done, and he was started on antituberculous therapy (ATT), namely, rifampicin, ethambutol, pyrazinamide, and isoniazid. After two weeks of ATT, the patient had developed Stevens-Johnson syndrome (SJS), and ATT was discontinued. His symptoms had improved with prednisolone 60 mg daily with tapering over the next preceding month, but ATT was not recommenced due to uncertainty of the diagnosis, because by that time, patient's symptoms had been resolved, and the sputum for tuberculosis (TB) culture was reported as negative.
Investigations done during the latter admission revealed white cell count of 10,000 with neutrophils of 89%, lymphocytes of 10%, eosinophils of 0.2%, hemoglobin at 7.2 g/dl, mean corpuscular volume of 93 fl, and platelets 278 x 103. The erythrocyte sedimentation rate (ESR) was 101 mm in the first hour, and C-reactive protein was 311 mg/dl. Chest radiograph showed left lower zone effusion with consolidation (see Figure 1). Considering the history and the high inflammatory markers with X-ray changes, a possible diagnosis of left lower lobe pneumonia with parapneumonic effusion was considered. Initially, he was treated with IV co-amoxiclav 1.2 g three times daily. Sputum for gram stain, acid-fast bacilli, was found to be negative. Sputum for pyogenic culture also did not isolate any organism after 72 hours of incubation. Ultrasound-guided aspiration of the pleural fluid was carried out and aspirated purulent blood-stained fluid. Lymph node fine needle aspiration or biopsy was not considered for several reasons. First, as it was situated on the left axilla, where the patient had his fistula made for the hemodialysis. Second is that the lymph nodes were found to be too small for sampling. Third was since they were deep seated, and it was difficult to gain access, and lastly, because of the possibility of arriving at a diagnosis by evaluating the effusion where access is easily gained.
The aspirate was analyzed with gram stain and AFB stain, which were negative. Pyogenic culture of the aspirate remained sterile after 72 hours. Full report of the aspirated fluid revealed 90% polymorphs and 10% lymphocytes. Lactate dehydrogenase (LDH) was 12,738 IU/l. Adenosine deaminase level (ADA) was 431 mu/l. Because of the high inflammatory markers and the neutrophil predominance, he was treated with intravenous (IV) meropenem 500 mg twice daily and with IV clindamycin 500 mg twice daily for two weeks. But since the ADA was very high, with relation to the past history, underlying tuberculosis infection was also considered. Therefore, aspirate fluid was sent for TB culture. While awaiting TB culture, subsequent CECT revealed empyema necessitans with destruction of the left side anterior upper rib associated with left pleural and mediastinal lymphadenopathy with the most probable infection of tuberculosis (see Figures 2 and 3).
The patient was referred to the thoracic surgical team, and they carried out incision and drainage of the lump since the effusion was minimal by that time with the drainage and the treatments. Abscess wall histology did not reveal caseating granulomas. The abscess fluid culture isolated 19 colonies of Mycobacterium tuberculosis organism after one month of incubation; hence, tuberculous empyema necessitans was confirmed.