Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease

Our plain-English summary of Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease, by M. Zantah, D. Datta (Respiratory Medicine Case Reports, 2017).

The study

• Authors: M. Zantah, D. Datta
• Journal: Respiratory Medicine Case Reports
• Published: 2017;21:135-137
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Chest-x-ray showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD). Pleural fluid was exudative with predominantly mononuclear cells, negative acid fast bacilli stain, negative cultures, and negative cytology for malignant cells. Due to recurrence of the effusion, 4 weeks after drainage, thoracoscopic pleural biopsy was planned but pleural fluid cultures came back positive for mycobacteria tuberculosis. Patient was started on anti-tubercular therapy but treatment had to be stopped due to liver toxicity. Patient subsequently developed pneumonia and deteriorated despite antibiotic therapy and expired.

In plain English

This is a case report. An 84-year-old man, a retired machinist who had never smoked, had two months of worsening breathlessness, productive cough and weight loss. He denied any known direct exposure to asbestos. A chest X-ray showed fluid around the right lung (pleural effusion) and calcified pleural plaques on both sides and on the diaphragm, which the authors described as consistent with asbestos-related pleural disease. The drained fluid showed no cancer cells, and early stains and culture found no organisms. The fluid returned, and he was hospitalized again five weeks after first presenting. By then, a tuberculosis culture of the first fluid sample had grown Mycobacterium tuberculosis, and tuberculous pleural effusion on top of asbestos-related pleural disease was diagnosed. Tuberculosis treatment was stopped after two weeks because of liver toxicity. He then developed pneumonia and died after comfort care was started. The authors called this, to their knowledge, the first reported case of its kind. They concluded that tuberculosis should be ruled out in such effusions because there may be a likely association between the two conditions.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 84-year-old man, a Korean War veteran and retired machinist who had never smoked. He had two months of progressive shortness of breath on exertion, productive cough and weight loss. The article does not state where or when he was treated.
• Exposure: The patient denied any known direct exposure to asbestos. Asbestos-related pleural disease was identified from imaging: calcified pleural plaques on both sides and diaphragmatic plaques. No fiber type or exposure source is given.
• Main results:
  • Chest X-ray showed a moderate right-sided pleural effusion and calcified pleural plaques on both sides, as well as diaphragmatic plaques, described as consistent with asbestos-related pleural disease (ARPD).
  • At the first thoracentesis, the fluid had WBC 2100 (7% neutrophils and 93% mononucleated cells). Gram stain showed no organisms and the culture later showed no growth. Cytology was negative for malignant cells and the AFB stain was negative.
  • A chest CT three weeks later showed a loculated right-sided pleural effusion and a pleural-based nodular density in the left lower lobe, with pleural plaques compatible with ARPD.
  • The patient was hospitalized again 5 weeks after his initial presentation with a recurrent right-sided effusion. On repeat thoracentesis, cytology, AFB stain and Gram stain were negative.
  • The AFB culture of pleural fluid from the first thoracentesis grew Mycobacterium tuberculosis. Tubercular pleural effusion superimposed on ARPD was diagnosed.
  • Treatment with isoniazid, rifabutin and ethambutol was stopped two weeks later because of liver toxicity. The patient developed health-care associated pneumonia, comfort measures were instituted, and he died.
• The authors' conclusion: The authors concluded that, although pleural effusion is a known manifestation of asbestos-related pleural disease, concurrent tubercular pleural effusion should be ruled out by appropriate microbiological and histopathological studies, because there may be a likely association between the two conditions. They described this as, to their knowledge, the first reported case of its kind.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Asbestos-Related Pleural Disease, Dyspnea, Bilateral, Pleural Plaques, Cytology, Pleural Biopsy.

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