Tuberculosis Pleuritis Treated With Intrapleural Lytics Complicated by Recurrence Requiring Video-assisted Thorascopic Surgery

Abstract Tuberculous pleural effusion is a product of Mycobacterium tuberculosis (TB) infection in the lung pleura. It is generally diagnosed by demonstrating granuloma in the pleura or via elevated adenosine deaminase (ADA) in the pleural fluid[1]. Current therapy recommendation is a regimen of isoniazid, rifampin, and pyrazinamide for two months followed by isoniazid and rifampin for four months[1]. There is no documented recommendation regarding intrapleural fibrinolytic therapy for treatment of pleural tuberculosis[2]. A 40-year-old female from El Salvador presents with two weeks of fevers, chills, and myalgias. On initial work-up she is found to have a large right pleural effusion without overlying infiltrate. Bedside ultrasound and thoracic imaging (Figure 1) were concerning for moderate septations, and patient subsequently had a thoracostomy tube placed with 400cc fluid drained. Fluid studies indicated exudative effusion with LD 915, protein 4.8, and glucose 58 without organisms on pleural culture. Subsequently, they were treated with six doses of alteplase and dornase installations into the pleural cavity over three days. Testing revealed negative AFB smear, however positive TB PCR, ADA, and Quantiferon gold suggesting pleural tuberculosis. Further history revealed that the patient's family member whom she had contact with was exposed to tuberculosis in the past year. Our patient was started on RIPE antibiotic therapy and discharged from the hospital with isolation instructions and scheduled follow-up. Thereafter, in outpatient pulmonary clinic, she had ultrasound performed which suggested a remaining effusion along with potential consolidation. Further imaging revealed loculated right pleural effusion with concern for entrapped lung. Patient was taken for a right video-assisted thorascopic surgery (VATS) and decortication with thoracic surgery. During the procedure, she was noted to have areas of granulomatous peel instead of the expected fluid collection. She also required wedge resection of her middle lobe at that time due to visceropleural disruption. Ultimately, there is minimal data regarding the use of intrapleural fibrinolytics in pleural tuberculosis. A prior case study notes seven cases of tuberculosis pleuritis that received intrapleural lytics and achieved remission[3]. The novelty of this case relates to the use of intrapleural lytics complicated by recurrence of pleural effusion requiring VATS and wedge resection. Interestingly, the area of concern on imaging was not consistent with previously assumed fluid and instead was a thickened granulomatous peel. This development further mystifies if intrapleural lytic therapy is appropriate in the management of complicated tuberculosis pleuritis or if it leads to increased complications compared to standard therapy.