Prepared by Trudy Seivwright, MD, Resident, Department of Obstetrics and Gynecology, Nadene Fair, MD, Resident, Department of Internal Medicine, and Eric Flenaugh, MD, FCCP, Coordinator, Department of Interventional Pulmonary Medicine, Morehouse School of Medicine, Atlanta, Ga
A 30-year-old (recent immigrant) Hispanic man presented to the emergency department with a 3-month history of left-sided pleuritic chest pain and difficulty breathing. The chest pain was accompanied by a 10-lb weight loss over 6 weeks, fever, and weakness, but no cough. A purified protein derivative (PPD) test performed during a recent incarceration was negative.
Physical examination revealed he had mild tachycardia and decreased breath sounds in the left lung base. Sputum stain was negative for acid-fast bacilli or other bacteria. Chest radiograph revealed left lower lobe atelectasis with a large pleural effusion (Figure 1). Computed tomography of the thorax showed similar findings, with nodular thickening of the visceral and parietal pleurae (Figure 2).
Empirical antibiotic treatment for community-acquired pneumonia was not helpful. A pleurocentesis done at admission yielded thick, lymphocytic, turbid, inflammatory fluid that clotted while awaiting laboratory findings. The microbiologic specimen was reported as “positive with acid-fast bacteria/high-power field.”
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