An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. He denied fever and hemoptysis. Past medical history was significant for hypertension, atrial fibrillation and diabetes mellitus. His medications included warfarin, metoprolol, glipizide, lisinopril, and simvastatin. The patient was a Korean War veteran and a retired machinist. He had never smoked in his life. He denied any known direct exposure to asbestos.
The patient was afebrile with normal vital signs. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Blood work showed stable normocytic anemia; serum chemistries were normal. Chest-x-ray (Fig. 1) showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD).
Thoracentesis revealed serous fluid, with glucose 130 mg/dL, LDH 884 mg/dL, protein 4.8gm/dL, pH 8, Albumin 2.39gm/dL, WBC 2100 (7% neutrophils and 93% mononucleated cells), RBC 64000. Fluid culture showed no organisms on gram stain and subsequently no growth. Cytology was negative for malignant cells. AFB stain was negative. Three weeks later, on outpatient follow-up, a chest CT scan (Fig. 2) showed a loculated right-sided pleural effusion, pleural-based nodular density left lower lobe with pleural plaques compatible with ARPD. A thoracoscopic pleural biopsy was planned but before this could be performed, the patient was hospitalized again, 5 weeks after his initial presentation, with worsening symptoms of shortness of breath. Chest x-ray revealed a recurrent right-sided pleural effusion. A repeat thoracentesis revealed glucose 42 mg/dL, LDH 746 mg/dL, protein 5.2 gm/dL, pH 7.5, albumin 2.19gm/dL, WBC 79, with 58% neutrophils, 42% mononucleated cells, RBC 2000. Cytology was negative for malignant cells. Acid fast bacilli (AFB) stain and Gram stain were negative. At that time, pleural fluid AFB culture from the first thoracentesis turned positive for mycobacterium tuberculosis and a diagnosis of tubercular pleural effusion, superimposed on ARPD, was made.
The patient was started on isoniazid, rifabutin and ethambutol. Treatment was stopped two weeks later due to development of liver toxicity. The patient subsequently developed health-care associated pneumonia and deteriorated clinically despite treatment with broad-spectrum antibiotics. Per the patients previously expressed wishes, comfort measures were instituted and he expired soon after.
Chest CT scan showing a loculated right-sided pleural effusion with calcified pleural plaques.