TB or Not TB: Two Unique Cases of Pleural Tuberculosis in Immunocompetent Hosts
Recommended Citation
Zahedi S, Khazmi I, Binette M, Rezik MM. TB or Not TB: Two Unique Cases of Pleural Tuberculosis in Immunocompetent Hosts. Am J Respir Crit Care Med 2025; 211:A2072.
Document Type
Conference Proceeding
Publication Date
5-20-2025
Publication Title
Am J Respir Crit Care Med
Abstract
A 36-year-old male (JF) who recently immigrated from Venezuela presented to the emergency department with a one-week history of nonproductive cough, fever, and night sweats. His roommate had been diagnosed with tuberculosis (TB). Chest X-ray revealed a large right-sided pleural effusion without parenchymal disease. JF was placed in isolation, but multiple attempts to obtain an induced sputum sample were unsuccessful. A Quantiferon-TB Gold test was positive, and a chest CT confirmed no parenchymal disease. The diagnosis of pleural TB was made based on pleural fluid analysis, which was exudative per Light's criteria and positive for adenosine deaminase (ADA), although acid-fast bacilli (AFB) testing was negative. He was discharged without airborne precautions and started on RIPE therapy. Two weeks later, JF's other roommate, a 35-year-old male (CG), presented with similar symptoms. CG's Quantiferon-TB test was also positive. He produced two sputum samples, which were AFB-negative but positive for Mycobacterium tuberculosis (mTB) PCR. Imaging revealed a large exudative pleural effusion, although ADA testing was not obtained, and pleural fluid AFB cultures were negative. Both patients had shared exposure to the same source and were HIV-negative. Despite their similar symptoms and pleural effusions, JF had isolated pleural TB, while CG had both parenchymal and pleural TB. JF's case is significant due to its rarity; isolated pleural TB constitutes only 5-10% of TB cases and usually arises from hematogenous or lymphatic spread. It is more common in younger patients or those with HIV, none of which applied to JF. Diagnosing pleural TB can be complex and typically requires a positive mTB PCR or ADA in pleural fluid; if both are negative, a pleural biopsy showing caseating granulomas and AFB positivity is necessary. Simultaneous parenchymal and pleural TB, as in CG's case, occurs in only 5-30% of TB cases and is often linked to a high disease burden or immunocompromised status. These atypical presentations emphasize the need for clinical vigilance and a thorough understanding of pleural TB's diagnostic challenges. Early recognition and treatment are essential to improve outcomes and prevent complications such as residual parenchymal fibrosis and increased relapse risk.
Volume
211
First Page
A2072
