Unilateral recurrent pleural effusion

Today we discussed a 54 yo M p/w gradually worsening dyspnea on exertion, pleuritic chest pain and cough which is intermittently productive of greenish sputum. Denies fevers/ hemoptysis/ wt loss. Similar symptoms a month ago when he was admitted to a hospital in Cape Verde he was found to have right sided pleural effusion-> 1L of cloudy yellowish fluid was drained-> fluid with lymphocytic predominance but neg AFB. Given 3 days of ciprofloxacin and discharged.

On further evaluation here, found to have a recurrent right sided pleural effusion (?loculated) on CXR with no other focal opacities. CT confirmed this, additionally R hilar lymphadenopathy but did not note any parenchymal lesions. PPD was + at 41 mm.

Teaching points:

  1. lymphocytic predominance in fluid with + PPD in patient from endemic area (without any other definitive diagnostic data to indicate TB) -> can be empirically treated as tuberculous pleuritis with 4 drug regimen
  2. if the above is not treated, 65% will progress to more progressive disease
  3. sensitivity of AFB in pleural fluid is <30% and pleural biopsy is 40-80% (preferred)
  4. To rule out trapped lung before performing a therapeutic drainage
  5. Pleural TB without parenchymal involvement is considered extra-pulmonary
  6. Pleural TB is more common in patients >65 yrs of age and US born (although this patient does not fit this profile)