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• W4387268252 abstract "SESSION TITLE: Disorders of Pleura Case Report Posters 10 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Tuberculosis (TB) is a highly infectious disease caused by Mycobacterium tuberculosis (MTB) that primarily affects the respiratory system. It is the second leading cause of infectious disease-related deaths. In the US, there were 7,882 cases of active TB in 2021. Pleural tuberculosis, a complication of active TB that can be life altering, affects 3% of individuals in the US and up to 30% of individuals in TB endemic areas. We present a case of severe pleural TB requiring surgical adhesiolysis. CASE PRESENTATION: A 36-year-old man who recently migrated to the US from Mexico initially presented to an outpatient urgent care, complaining of shortness of breath, headache, nausea, and vomiting. Chest X-ray conducted revealed a large left-sided lung opacity, and he was transferred to our emergency department (ED). In the ED, the patient was tachycardic, saturating 94% on room air. The initial respiratory biofire panel was negative, and he was started on antibiotic coverage for community acquired pneumonia. Further CT imaging of the chest revealed a left pleural effusion and severe left upper and lower lobe atelectasis. Pulmonology was consulted, a left thoracentesis was performed, and 3 Liters of straw-colored fluid was removed. Fluid analysis was suggestive of exudative effusion with lymphocytic predominance, low glucose, and negative cytology. Bacterial and Acid-Fast Bacilli (AFB) cultures returned negative. This left pleural effusion recurred; thus, a percutaneous chest tube was placed. Autoimmune work-up was negative and pleural fluid Adenosine-DeAminase (ADA) was normal at 27. There was persistent high suspicion of a TB effusion. A pleuroscopy was performed, and he was found to have complex pleural loculation requiring extensive adhesiolysis and pleural biopsies were taken. Pathology revealed caseating granulomas consistent with tuberculosis, and the patient was started on anti-tuberculosis therapy. Patient subsequently underwent a decortication of the left lung and was discharged with the County Tuberculosis clinic follow-up. DISCUSSION: Pleural TB can have severe consequences and require complex management, as illustrated in the presented case. The pathogenesis of Pleural TB was thought to be a delayed hypersensitivity reaction. However, now it suggests a T-Helper type-1 response to acquired infection of pleural space from the lung parenchyma resulting in granuloma formation and contained fluid with mycobacteria. With high suspicion, a diagnosis can often be inferred with just lymphocytic predominant exudative pleural fluid with high ADA. If not, it requires a pleural fluid / pleural biopsy showing culture positive for AFB organisms and caseating granulomas, like in our patient. Pleural fluid is expected to reabsorb within 6-8 weeks of treatment initiation in most cases. Previous studies have demonstrated that early pleural drainage in addition to antimicrobial therapy improves lung function and decreases pleural thickness 6 months post infection, thus preventing worse clinical symptoms. The role of surgery is not well established but reported in refractory cases. CONCLUSIONS: Though incidence of TB in the US is lower compared to the rest of the world, a strong suspicion in high-risk patient population is essential for early detection so that a timely intervention may help to improve clinical outcomes. REFERENCE #1: Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CF. Tuberculous pleural effusions: advances and controversies. J Thorac Dis. 2015 Jun;7(6):981-91. doi: 10.3978/j.issn.2072-1439.2015.02.18. PMID: 26150911; PMCID: PMC4466424. REFERENCE #2: Morrone, N., M. C. Lombardi, and O. Machado. Prevention of pleural thickening through pleural aspiration in patients with tuberculous effusion. J Pneumol (Sao Paulo) 15 (1989): 180-4. REFERENCE #3: Bhuniya S, Arunabha DC, Choudhury S, Saha I, Roy TS, Saha M. Role of therapeutic thoracentesis in tuberculous pleural effusion. Ann Thorac Med. 2012 Oct;7(4):215-9. doi: 10.4103/1817-1737.102176. PMID: 23189098; PMCID: PMC3506101. DISCLOSURES: No relevant relationships by Cliff Chen No relevant relationships by Annette Eom No relevant relationships by Rathnavali Katragadda No relevant relationships by Palakkumar Patel No relevant relationships by Melissa Rosas No relevant relationships by Scott Turnbull" @default.
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• W4387268252 date "2023-10-01" @default.
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• W4387268252 title "SEVERE PLEURAL TUBERCULOSIS: A CASE REPORT AND MANAGEMENT CHALLENGES" @default.
• W4387268252 doi "https://doi.org/10.1016/j.chest.2023.07.2429" @default.
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