CRA55 SUCCESSFUL MANAGEMENT OF COMPLICATED TUBERCULOUS PLEURAL EFFUSION WITH NON-EXPANDABLE LUNG USING INTRAPLEURAL FIBRINOLYTIC AND ENZYME THERAPY

Jacelyn Heng Yi Ting¹, Boon Hau Ng¹, Nor Safiqah Sharil^1,2, Rose Azzlinda Osman¹, Hsueh Jing Low³, Nik Nuratiqah Nik Abeed¹, Andrea Yu-Lin Ban¹

1.      Respiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
2.      Department of Anesthesiology and Critical Care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
3.      Internal Medical Unit, Faculty of Medicine and Health Science, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan.

Introduction
Tuberculous pleural effusion can be complicated by complex effusion and a non-expandable lung, leading to persistent respiratory symptoms. Intrapleural fibrinolytic and enzyme (IPFE) therapy can be considered as an alternative treatment to facilitate drainage and lung re-expansion in such cases.

Case Report
A 56-year-old man presented with a one-month history of cough and dyspnea. Examination revealed reduced breath sounds and stony dullness over the right hemithorax. Thoracic ultrasound showed a hypoechoic pleural effusion spanning six rib spaces with pleural thickening. Contrast-enhanced computed tomography of the thorax revealed a right hydropneumothorax with a split pleura sign, diffuse pleural thickening, and upper lobe consolidation with a tree-in-bud pattern.

Pleural fluid analysis revealed an elevated adenosine deaminase level of 47 U/L, while the TB PCR test was negative. Pleuroscopy revealed discrete white nodules, and histopathology confirmed chronic necrotising granulomatous inflammation, leading to a diagnosis of pleural tuberculosis. The patient was initiated on anti-TB therapy. Post-pleuroscopy, the right lung remained non-expandable despite suction drainage (Figure 1). Repeat ultrasound showed multiloculated effusion. Sequential IPFE therapy was administered every 12 hours, consisting of three doses of alteplase (5 mg) and dornase alfa (5 mg) with a dwell time of 45 minutes. A total of 1950 mL of fluid was drained, and the right lung was successfully re-expanded.

Discussion
Non-expandable lung and multiloculated effusion pose significant management challenges in TB pleuritis. While surgical intervention is often considered, IPFE therapy offers a minimally invasive alternative to enhance drainage and improve lung expansion. This case highlights the efficacy of IPFE in resolving a complex TB pleural effusion, reducing the need for more invasive procedures.