CASE PRESENTATION
History and Exam : We received a 28-year-old woman, no known
chronic illnesses, HIV-seronegative, one month in puerperium having
delivered by cesarean section, referred from the obstetrics unit because
of persistent chest pain. The pain started when she was 7months
pregnant, more on the right side, pleuritic in nature and had
progressively increased over time and worsened after delivery.
Post-delivery, she also started experiencing evening fevers, lost
appetite, and got episodes of difficulty in breathing while lying down
and/or sleeping. She had no cough. On examination she was in a fair
general condition, not in respiratory distress but worried. Vital signs
were: blood pressure 130/80mmHg, pulse 112 beats/minute, Temperature
37.8°C, peripheral saturation of oxygen(SpO2) 96%, respiratory rate
19breaths/minute. Significant findings on chest exam was stony dullness
and reduced air entry in the right subscapular and basal lung
zones.
Methods : A clinical diagnosis of right pleural effusion was
made and patient sent for a chest x-ray (figure1 ) which
confirmed an effusion. TB and malignancy were suspected as the cause of
the effusion because of the long standing history and constitutional
symptoms. Diagnostic thoracentesis was performed and fluid samples taken
for ZN Stain, Gene expert, Gram-stain, Culture and cytology. We didn’t
do pleural biopsy due to lack of thoracoscopy. ZN Stain reported no acid
fast bacilli, Gene expert reported no Mycobacterium tuberculosis
detected and Gram-stain revealed no organisms. There was no growth on
culture. Fluid cytology revealed scattered lymphocytes and polymorphs on
a serous background(figure2 ), thus deducing as chronic
lymphocytic pleuritis. There were no malignant cells, no TB on
cytological exam. A second pleural fluid sample was taken off for ADA
test, having seen the chronic lymphocytic picture of the first sample.
ADA test result was 58.6 U/L (Biological Reference Interval 0-40). Based
on these findings she was diagnosed with TBP five days after
presentation and started on TB chemotherapy composed of rifampicin,
isoniazid, ethambutol and pyrazinamide for 2months and Rifampicin and
Isoniazid for 4months.
Outcome and follow-up: Treatment commenced on June
1st 2023 and completed on November
30th 2023 with 100% adherence as indicated on
adherence monitoring tool (figure3 ). By two months of treatment
(July 27th 2023), the effusion had reduced by almost
90%(figure4 ), and completely resolved by 1stDecember 2023 (figure5 ). She has since been fine, was last
reviewed on 9th February 2024 with normal general and
chest findings.