International Journal of Clinical Case Reports 2013, Vol.3, No.4, 26
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Aspiration of loculated collection was done on the
clinical suspicion of infective pathology and sent for
ADA (adenosine deaminase), cytology, and biochemical
tests. The fluid was negative for m alignant cells, but
ADA level was raised 73.6 U/L.
The clinical presentation of prolonged fever supported
by the raised level of ADA in the loculated pleural fluid
suggested a diagnosis of Tuberculosis. The patient was
started on HREZ. The doses were Isoniazid (H)
-
5
mg/kg, Rifampicin(R)
-
10
mg/kg, Pyrazinamide(Z)
-
25
mg/kg, Ethambutol(E)
-
15
mg/kg. The drugs were
started on daily basis and regime was initial two months
of intensive phase followed by four months of
continuation phase.
After one week of initiation of ATT patient developed a
sudden bout of vomiting and vomited copious yellowish
pus like fluid around 100~150 mL with tinge of blood at
the beginning. To evaluate these sudden onset new
symptoms he was reassessed and diagnosis of impaired
liver function was made and i nvestigated accordingly,
the liver functions turned out to be within normal range.
From the very next day pt. was symptomatically better
and on chest examination breath sounds were normal on
both sides. A follow-up chest radiograph was done
which showed normal both lung fields except for mild
bi-hilar prominence (Figure 3).
Such a sudden disappearance of the lung shadows is
Figure 3 Chest r adiograph was done which show ed normal both
lung fields except for mild bi-hilar prominence
Note: Date on film is the capturing date
very unusual and prompted us a search to explain the
discharge of collection through esophagus.
A barium meal continuation was carried out which
revealed no evi dence of any abnormal tract/fistula.
There was focal thickening of the oblique foramen in
the upper part therefore CECT examination of the chest
was done to rule out any subtle abnormality inside in
plain radiograph examination in barium swallow
(
Figure 4). It showed a small patch of consolidation in
right side lower zone.
Figure 4 CECT examination of the chest
He took ATT for six months and in the follow up of one
year he remained asymptomatic.
Discussion
The presence of Pleura l effusion in tuberculosis can
range from 4% to 25 % cases depending of endemicity
of disease and many other factors (Qiu et al., 2006;
Valdes et al., 1996). In India the rate of pleural effusion
is about 20% cases of tuberculosis (Sharma and Mohan,
2004).
Typically it occurs 4~7 months following initial
infection. It is caused by rupture of small sub-pleural
focus (Berger and Mejia, 1973) and leads to obstruction
of the lymphatic pores in the parietal pleura which
causes accumulation of protein in pleural cavity. In the
natural history, tuberculous pleuritis usually resolves
spontaneously, but the patient frequently develops
active TB at a lat er date. The mean duration for
complete resorption of the pleural fluid is approximate-
ly 6 weeks, but it can be as long as 12 weeks (Tani et al.,