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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 302-304

A case report of tuberculous empyema: A tricky disease


Institute of Biomedical Sciences, Shanxi University, Taiyuan, China

Date of Web Publication12-Sep-2019

Correspondence Address:
Dr Muhammad Tufail
Institute of Biomedical Sciences, Shanxi University, Taiyuan 030006
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_110_19

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  Abstract 


Extrapulmonary tuberculosis (TB) can rarely be transmitted to others. The disease mostly affects adults and immunocompromised individuals. A 26-year-old male presented with weight loss and occasional chest pain with a deep breath, but he was otherwise normal. The patient had a history of severe dry coughs, night sweats, fever, confusion, and dizziness for >3 weeks. The patient was initially misdiagnosed with an allergic cough and was treated with anti-allergic medications. Due to small and sticky effusion, the thoracentesis procedure failed, and the patient was referred to a thoracic surgeon for an open decortication. Pleural biopsy (PB) was negative for acid-fast bacilli, but the report showed necrotizing granulomatous inflammation. The patient was started on anti-TB treatment according to the WHO guidelines. The patient gained about 6% of the body weight at the end of the intensive phase and about 15% of the body weight at the end of the continuation phase. His chest pain subsided. Chest radiography showed improvement. The patient recovered, and no relapse occurred. This study recommends that a patient with dry coughs, night sweat, and fever for >3 weeks should be followed up with a chest X-ray for at least the next 3 months.

Keywords: Open decortication, pleural empyema, tuberculosis


How to cite this article:
Tufail M. A case report of tuberculous empyema: A tricky disease. Int J Mycobacteriol 2019;8:302-4

How to cite this URL:
Tufail M. A case report of tuberculous empyema: A tricky disease. Int J Mycobacteriol [serial online] 2019 [cited 2019 Oct 19];8:302-4. Available from: http://www.ijmyco.org/text.asp?2019/8/3/302/266487




  Introduction Top


Tuberculosis (TB) affects about one-quarter of the world population, but only a small fraction gets sick. The increase or decrease in the TB cases is due to hygiene, not vaccine campaigns.[1] According to an estimation in 2016, 1.7 million TB patients died (374,000 were infected with HIV), whereas 10.4 million incidence cases occurred. Extrapulmonary TB (EPTB) is a rare form of TB which comprised about 14%–15% from 2005 to 2007, which increased up to 20% in 2010–2013.[2] EPTB is a noncontagious form of TB and can be infectious in case of contact with infected lesions during diagnostic or therapeutic procedures. Among EPTB, pleural TB is the second most common variant in adults and the major cause of pleural effusion.[3] The reason for this incrimination is still not clear. Although misdiagnosis of the disease, difficulty in the diagnosis of EPTB, considering lower voluntary reporting, it is probable that the real proportion of EPTB was higher compared to report. Various factors are associated with EPTB including Asian and African origin, male gender, adulthood, and HIV susceptibility.[4]

Culturing of Mycobacterium tuberculosis is the best way to diagnose TB. Unfortunately, in the case of EPTB, it is difficult to obtain a sample from the infected site. Because the sensitivity of conventional smear microscopy is low with a range of 0%–40%, negative results cannot eliminate the presence of TB.[5] The reported yields of mycobacterial culture vary from 30% up to 80%, but the approximate duration of getting the results is 2–8 weeks, which is too long.[6] In EPTB, surgery is mostly required to obtain a valid diagnostic sample (biopsy).

Multidrug therapy is used to treat active TB. Anti-TB medications are usually given in combination and not as a single agent. Individuals with inactive TB are usually treated with isoniazid (INH) or rifampin (RIF) or a combination of these two medicines.[7]


  Case Report Top


A 26-year-old male was referred to the Pulmonology Unit, Lady Reading Hospital (LRH), Peshawar, Pakistan. The patient was diagnosed with a small effusion with consolidation in the right lung. Previously, he was misdiagnosed with an allergic cough. According to the patient's medical history, 6 months earlier, he suffered from a severe dry cough, shortness of breath, occasional fever, and sweat and chills at night for >3 weeks. The patient also experienced dizziness and confusion. The doctors prescribed him some anti-allergic medications, and the patient improved. After 3 months, the patient experienced excessive production of phlegm without experiencing any other abnormality. Then, the patient was prescribed some medicines to get rid of phlegm. On the 6th month, the patient started experiencing occasional chest pain with a deep breath. This time, the patient was advised for chest X-ray and ultrasound. The X-ray and ultrasound reports showed a small effusion with consolidation on the right side of the lung [Figure 1]. Decrease in the level of both total protein fluid (0.15 g/dl) and glucose fluid (2 mg/dl) was observed, whereas lactate dehydrogenase level (444 U/L) increased. Thoracentesis procedure failed due to a sticky and small effusion. Therefore, the patient was started on 1 month of antibiotic trial pneumonia, but no improvement was seen. The patient was unable to produce sputum, and therefore, he was referred to a thoracic surgeon for an open decortication. The patient was diagnosed with a loculated empyema. After decortication, the biopsy report was negative for acid-fast bacilli, but the report showed necrotizing granulomatous inflammation. The patient was started on anti-TB treatment. Initially, INH, RIF, and pyrazinamide (PZA) were included in the intensive phase for 2 months, whereas INH, RIF, and ethambutol (EMB) were included in the continuation phase. The dosage was prescribed according to the patient's body weight. The patient started gaining weight at the end of the intensive phase and gained about 15% of the body weight at the end of the 1-year therapy. His chest pain subsided, the ultrasound report was negative, and the chest X-ray showed improvement. However, after 6 months of therapy, the patient experienced Gastroesophageal reflux disease (GERD), headache, and occasional numbness. The GERD was treated with omeprazole.
Figure 1: (a) Chest X-ray before decortication. (b) Chest X-ray after decortication

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  Discussion Top


This is a classic case of tuberculous loculated empyema, as it presented subacutely in a male with a dry cough, shortness of breath, weight loss, chest pain, dizziness, confusion, night sweats, and loculated empyema. The TB rate is higher in males compared to females, with a ratio of 2:1, and in 70% of patients, it presents subacutely. More than 95% of TB pleural effusions are unilateral.[8] The etiology of effusion is difficult to classify and usually requires clinical correlation and pleural fluid (PF) analysis.[9]

The best diagnostic approach of pleural TB is still under debate. The yield of PF smears is 10% and of PF cultures is 25%–85%.[1] The diagnostic yields range from 55% to 93% in culture plus PB histopathology of granulomas.[10] Normal adenosine deaminase level is <40 U/L. A high level of ADA and lymphocytic pleural effusion strongly points toward TB.[11] Compared to PF examination, the detection rate of microbial examination of PB specimens is higher.[12] The specific metabolisms for tuberculous effusion are creatine, L-alanine, and citric acid. The citric acid level decrease in both tuberculous effusion and diabetes.[13]

According to the American Thoracic Society, the treatment duration for pleural TB is a 6-month regimen consisting of a 2-month intensive phase (INH, RIF, PZA, and EMB) followed by 4 months of continuation phase (INH and RIF).[14] Corticosteroids are not recommended for pleural TB as they are not found effective in reducing residual pleural thickening.[15] Therapeutic thoracentesis is controversial, and there is no discussed guideline; however, it is usually recommended if a patient is more than slightly symptomatic.[16] The accelerated recovery of pulmonary function and pleural thickness is significantly less in effusion-associated TB patients who have received therapeutic thoracentesis for TB.[17] However, in other studies, no influence was observed on residual pleural thickening by this intervention.[18] Other drawbacks to this procedure include the transmission of the disease to the health providers, lung injury, and bleeding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Maes R. Tuberculosis serology is useful in rural areas. Biomed Biotechnol Res J 2017;1:85-93.  Back to cited text no. 1
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2.
Korea Centers for Disease Control and Prevention. Annual Report on the Notified Tuberculosis in Korea. Cheongwon: Korea Centers for Disease Control and Prevention; 2014. p. 2013.  Back to cited text no. 2
    
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Kawamura I, Kudo T, Tsukahara M, Kurai H. Infection control for extrapulmonary tuberculosis at a tertiary care cancer center. Am J Infect Control 2014;42:1133-5.  Back to cited text no. 3
    
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Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CF. Tuberculous pleural effusions: Advances and controversies. J Thorac Dis 2015;7:981-91.  Back to cited text no. 4
    
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Lee JY. Diagnosis and treatment of extrapulmonary tuberculosis. Tuberc Respir Dis (Seoul) 2015;78:47-55.  Back to cited text no. 5
    
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Canadian Thoracic Society and the Public Health Agency of Canada and Licensors. Canadian Tuberculosis Standards. 7th ed. Ottawa: Public Health Agency of Canada; 2013.  Back to cited text no. 6
    
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Centers for Disease Control and Prevention. Treatment Options for Latent Tuberculosis Infection. TB Elimination; 2005.  Back to cited text no. 7
    
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Porcel JM. Tuberculous pleural effusion. Lung 2009;187:263-70.  Back to cited text no. 8
    
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Light RW. Update on tuberculous pleural effusion. Respirology 2010;15:451-8.  Back to cited text no. 9
    
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Sakuraba M, Masuda K, Hebisawa A, Sagara Y, Komatsu H. Thoracoscopic pleural biopsy for tuberculous pleurisy under local anesthesia. Ann Thorac Cardiovasc Surg 2006;12:245-8.  Back to cited text no. 10
    
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Bayhan GI, Sayir F, Tanir G, Tuncer O. Pediatric pleural tuberculosis. Int J Mycobacteriol 2018;7:261-4.  Back to cited text no. 11
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12.
Amer S, Hefnawy AE, Wahab NA, Okasha H, Baz A. Evaluation of different laboratory methods for rapid diagnosis of tuberculous pleurisy. Int J Mycobacteriol 2016;5:437-45.  Back to cited text no. 12
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Sookaromdee P, Wiwanitkit V. Tuberculous pleural effusion: Modification of metabolome by the effect of common metabolic disease, diabetes mellitus. Biomed Biotechnolo Res J 2019;3:19-21.  Back to cited text no. 13
    
14.
American Thoracic Society, CDC, Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep 2003;52:1-77.  Back to cited text no. 14
    
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Wyser C, Walzl G, Smedema JP, Swart F, van Schalkwyk EM, van de Wal BW. Corticosteroids in the treatment of tuberculous pleurisy. A double-blind, placebo-controlled, randomized study. Chest 1996;110:333-8.  Back to cited text no. 15
    
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Ocaña I, Martinez-Vazquez JM, Segura RM, Fernandez-De-Sevilla T, Capdevila JA. Adenosine deaminase in pleural fluids. Test for diagnosis of tuberculous pleural effusion. Chest 1983;84:51-3.  Back to cited text no. 16
    
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Bhuniya S, Arunabha DC, Choudhury S, Saha I, Roy TS, Saha M. Role of therapeutic thoracentesis in tuberculous pleural effusion. Ann Thorac Med 2012;7:215-9.  Back to cited text no. 17
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Lai YF, Chao TY, Wang YH, Lin AS. Pigtail drainage in the treatment of tuberculous pleural effusions: A randomised study. Thorax 2003;58:149-51.  Back to cited text no. 18
    


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