CRA48 TRANSUDATIVE PLEURAL EFUSION IN MULTIDRUG RESISTANT PLEURAL TUBERCULOSIS

Syuhada Zakaria, Sarah Naili Che Mohd Azmi, Shivaanandh, Noor Izyani Zakaria, Wan Jen Lye

Respiratory Unit, Internal Medicine Department, Hospital Selayang, Selangor.

Background
The incidence of tuberculosis is rising in Malaysia from 90 to 122 per 100,000 population in 2020 to 2023. Multidrug-resistant (MDR-TB) incidence in 2023 is 1.7 (1.1–2.2) per 100,000 population. Pleural tuberculosis is the second most common cause of extrapulmonary tuberculosis.

Case presentation
69 years old man, ex-smoker for 20 pack years from an elderly care facility, presented with progressive breathlessness and weight loss for 4 months associated with palpitation and leg swelling. His comorbidities include type 2 diabetes mellitus, hypertension, dyslipidemia, heart failure and atrial fibrillation. He has multiple histories of admissions for bilateral pleural effusion whereby thoracocentesis revealed transudative effusion with low adenosine deaminase (ADA) (12.94U/L, ref <29.6) however grew mycobacterium tuberculosis (MTB) complex. He was readmitted for repeat thoracocentesis which again showed transudative effusion with low ADA (left sided effusion, 6.89U/L, Right sided effusion 8.47U/L), negative Xpert MTB/RIF. Pleural fluid cytology showed lymphocytes and mesothelial cells. The full report for the initial pleural fluid culture revealed MTB complex with isoniazid and streptomycin resistance with a mutation in inhA gene. In view of persistent symptoms with recurrent pleural effusion and positive culture, he was treated for Isoniazid resistant pleural tuberculosis.

Discussion
The gold standard for diagnosing pleural tuberculosis remains the detection of MTB in pleural fluid, pleural biopsy specimens or histological demonstration of caseating granulomas in the pleura with acid fast bacilli. Typically, the character of pleural fluid in pleural tuberculosis is exudative however there have been rare cases reported of transudative effusion. One of the cause of infective pleural effusion presenting as a transudative effusion is concomitant cause of transudative pleural effusion like heart failure.