A 22 year-old Asian male smoker presented with ten days of non-productive cough, subjective fevers, night sweats, right-sided pleuritic chest pain and increasing dyspnea. One week prior to presentation, he was empirically treated for pneumonia with levofloxacin without improvement. The patient was an exchange student from China whose last visit home was two months prior to presentation to our facility. Both of the patient's parents had been diagnosed with TB before his birth with unclear treatment status.
The patient's physical exam was remarkable for decreased right-sided breath sounds. Vital signs were: temperature, 98.4  F; heart rate, 102/min, regular; BP, 102/58 mm Hg; respiratory rate, 28/min; oxygen saturation, 95% on room air.
Chest radiograph (CXR) showed a large right hydropneumothorax and right upper lobe infiltrate with scarring (Fig. 1). A right-sided 32 French chest tube (CT) was placed in the emergency department (Fig. 2A). A chest computed tomography scan showed tree-in-bud nodularity in the right upper lobe, possible consolidation in the right lower lobe and calcified hilar lymphadenopathy. Additionally, there were foci of gas in the right-sided hydropneumothorax which could have represented a loculated component. Due to imaging findings suggesting prior granulomatous infection and patient history, there was high suspicion for TB and on airborne precautions were instituted.
A pleural drainage catheter was placed into the hydropneumothorax. Analysis of the pleural fluid obtained from this procedure revealed: pH, 7.70; glucose, 11 mg/dL; protein, 4.5 g/L; LDH, 1458 units/L; WBC, 1340 cells/muL (64% lymphocytes); RBC, 4000 cells/muL; adenosine deaminase (ADA), 57.5 units/L. Additionally, serum protein was 5.6 g/L.
Throughout his hospitalization, the patient had multiple AFB smears and cultures performed (2 concentrated sputum, 2 pleural fluid, 1 bronchoalveolar lavage), which were negative. A pleural biopsy demonstrated 1+ AFB on smear and necrotizing granulomatous inflammation. The patient was started on an anti-tuberculosis regimen (isoniazid (INH) 300 mg, ethambutol (EMB) 800 mg, rifampin (RIF) 450 mg and pyrazinamide (PZA) 1000 mg) because of his findings of a lymphocyte predominant exudative pleural effusion, AFB positive pleural biopsy with necrotizing granulomatous inflammation and history of exposure to TB.
Given the persistent pleural effusion, he was given four doses of tissue plasminogen activator (tPA) and dornase alfa (DNase) instilled via the chest tube over a period of 6 days resulting in improved drainage and clinical and radiologic improvement (Table 1, Fig. 2B). Fibrinolytic therapy was terminated at the point of near complete resolution of the pleural effusion as evidenced by CXR. The chest tube was removed and the patient was discharged on hospital day 13. Two weeks after discharge, a follow-up CXR demonstrated a persistent small right-sided effusion, however; the patient was asymptomatic (Fig. 3). Ultimately, the pleural fluid and biopsy cultures were positive for Mycobacterium tuberculosis.