CRA88 A GUESSING GAME OF MIMIC

Soon Keat Tan¹, Justin Yu Kuan Tan^1, V.Shoban Raj¹. Han Loong Tan¹ Anez Azlan¹ Dass Raymund¹

¹ Hospital Tuanku Ja’afar, Seremban, Malaysia

Background
Infective exudative effusion can be proven challenging in differencing between bacteria parapneumonic effusion and tubercular effusion in case of acute presentation with no risk factor.

Case Report
We herein present A 22-year-old Chinese man presented with fever and cough for one week.He has no tuberculosis (TB) contact. His Chest X-ray show right moderate pleural effusion, and a chest tube was inserted in view of respiratory distress. Pleural fluid was sent for analysis, which showed an exudative picture based on Light’s criteria. Sputum and pleural acid-fast bacilli test were negative. Pleural cytology shows lymphocyte predominant with no atypia, pleural adenosine deaminase (ADA) was pending. Pleuroscopy was subsequently performed as he was not improving and to exclude pleural TB. Findings shows inflamed pleural with multiple septation typical of complicated parapneumonic effusion. He was referred to thoracic surgeon for decortication in view of unresolved complex pleural effusion and prolong chest drainage however his histopathological examination (HPE) revealed caseating granulomatous inflammation. With this finding he was diagnose as pleural tuberculosis and started on first-line anti-Tuberculosis medications, with a two-month intensive phase followed by four months of maintenance therapy. The result of pleural fluid Mycobacterium tuberculosis culture was positive and susceptible to all first-line anti-Tuberculosis medications, including Streptomycin, Isoniazid, Rifampicin, and Ethambutol while ADA was raised to 55.77 U/L. Compliance was ensured through Directly Observed Therapy (DOT). The patient achieved full recovery without major complications, as evidenced by the clearing of consolidations on chest X-ray, a negative sputum acid-fast smear, and the resolution of clinical symptoms.

Discussion
The diagnosis of tuberculosis can be challenging as our case he presented with acute history and he had no tuberculosis contact. Pleuroscopy finding were typical of complicated parapneumonic effusion and following British thoracic society guidelines 2023 recommendation, surgeon was consulted which they agree for decortication. This procedure was aborted as HPE reveals caseating granuloma hence avoiding surgery. In retrospective, pleuroscopy can be avoided if the turn over time for ADA was made available earlier as pleural tuberculosis can be treated with anti TB medication without invasive procedure.

Conclusion
An index of suspicion of tuberculosis should come in mind when it comes to unexplained exudative pleural especially in a moderate TB burden country.

Keywords: Exudative pleural effusion, Complicated parapneumonic effusion, Pleural Tuberc