An 83-year-old woman presented to the emergency department with a seven-day history of productive cough with dark sputum, dyspnea on exertion, symmetrical leg swelling, and left pleuritic chest pain. She had a history of pulmonary tuberculosis (PT) at the age of 15 years, and at that time, she had undergone several procedures that she could not recall. She had not been treated with antimycobacterial antibiotics. She also had hypertension and an ischemic stroke with residual memory deficits. She had recently been submitted to an echocardiogram, which had shown a non-dilated left ventricle, septum hypertrophy, and good systolic function, with no valvular dysfunction. On physical examination, her oxygen saturation was 95% on room air and her heart rate was 105 beats per minute. Auscultation revealed diminished lung sounds on the left posterior hemithorax, where a long thoracic scar was observed. Fine crackles could also be heard throughout the lungs, and mild pitting edema was present on both feet. Her blood workup was relevant for elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) of 839 pg/mL (normal value: <125 pg/mL), and slightly elevated reactive C-reactive protein of 6.3 mg/dL. No changes in blood count, or kidney or liver function were present (Table 1).
Her chest X-ray revealed an oval-shaped peripherally calcified mass on her left apex compatible with oleothorax (Figures 1, 2), and a linear calcified image (Figure 1) was seen on the internal right lateral thorax wall, consistent with calcified pleural plaques from TB pleurisy. The patient had been previously unaware of this finding and had no previous respiratory or thoracic symptoms.
The patient was diagnosed with de novo acute heart failure, triggered by community-acquired bronchitis, and was treated with intravenous furosemide and amoxicillin-clavulanate, and soon discharged with the same medications in oral formulations.