Pleural effusions recur! Anti-tuberculosis treatment failed, I didn't expect it to be this disease ...

Patient, female, 66 years old, married, unemployed
.

Complaints: Anti-tuberculosis treatment for more than 3 months, more than 10 days
.

More than 3 months ago, the patient had "cough and sputum with bloodshot sputum in the sputum for half a year
.
"Admitted to the infectious disease department of our hospital, after a comprehensive examination, consider: 1.
secondary pulmonary tuberculosis sputum coating negative, sputum tuberculosis DNA positive, initial treatment; 2.
tuberculous pleurisy (right).

Isoniazid, rifampicin, ethylaminobutol hydrochloride, pyrazinamide combined with anti-tuberculosis drugs, spironolactone tablets were given water, and pleural effusion was reduced
.

During hospitalization, he underwent multiple right-sided thoracentesis aspiration under color Doppler ultrasound positioning, and chest CT after half a month of treatment showed a decrease in pleural effusion, and he is currently treated with oral isoniazid, rifampicin, ethylaminobutol hydrochloride, pyrazinamide anti-tuberculosis therapy, and liver protection and support therapy for more than
3 months.
More than 10 days ago, the patient complained of gastrointestinal reactions, poor nutrition, decreased appetite, and obvious shortness of breath after taking tuberculosis drugs, and stopped tuberculosis drugs by himself for a week
.

This outpatient review chest CT suggests: 1.
A large amount of fluid in the right chest cavity and incomplete distension in the right lung; 2.
The cardiac shadow is enlarged, and the pericardium is light and moderate in the amount of effusion
.
Compared with the previous film, the right pleural effusion is increased, and hospitalization
is recommended.

Outpatient clinics with "1.
Infiltrative tuberculosis; 2.
Tuberculous pleurisy; 3.
Pleural effusion; 4.
Pericardial effusion; 5.
Bronchial tuberculosis" admitted to the hospital
.

The patient developed cough and sputum with bloodshot symptoms in sputum more than 3 months ago, and chest CT before admission suggested: 1.
Infectious lesions in the right lung, considered secondary pulmonary tuberculosis and the possibility of incomplete distension of the upper lobe of the right lung, right pleural effusion, pericardial effusion
。 Admission to check tuberculosis smear examination (instrumental method) + direct smear acid-fast staining microscopy (sample: sputum): negative, chest color ultrasound showed that the right chest cavity was visible about 7.
6cm small flakes without echo, considering the right pleural effusion, the tuberculin test was positive PPD (7×9mm), the tuberculosis antibody was weakly positive, the rinterferon release test (TB-TGRA) was negative, the sputum tuberculosis DNA test was positive, and the culture of sputum tuberculosis bacillus was negative
.

At present, the diagnostic criteria for positive molecular biology of pulmonary tuberculosis in the diagnostic criteria for pulmonary tuberculosis (WS288-2017) (WS288-2017 5.
3.
3) ^{have been met[3].}

The patient's imaging showed a right pleural effusion, pleural fluid routine showed yellow opacity, clot, positive Li Fanta's test (+++), nucleated cells 200×106 /L (exudative), percentage of neutrophils 32%, percentage of lymphocytes 68%; Negative acid-fast staining of pleural fluid, negative DNA determination of tuberobculi pleural fluid, biochemistry of pleural fluid showed glucose 6.
50mmol/L, adenosine deaminase 65.
8U/L (tuberculous pleurisy: adenosine deaminase >45U/L), lactate dehydrogenase 138U/L, indicating that the nature of pleural fluid met the diagnostic criteria for the clinical diagnosis of tuberculous pleurisy (WS288-2017 5.
2.
g).

In accordance with the Technical Specifications for Tuberculosis Prevention and Control in China (2020 Edition) ^[4] and the Clinical Diagnosis and Treatment Guidelines and Tuberculosis Fascicle ^[5], anti-tuberculosis drug treatment and thoracentesis were given
.

However, after anti-tuberculosis treatment for more than 3 months, the patient has undergone thoracentesis for many times, and this outpatient review CT shows an increase in pleural fluid, and the cause of poor pleural fluid absorption needs to be further investigated: is the anti-tuberculosis treatment effect is not good, or is there another hidden situation?

After admission, no obvious abnormalities
were found in cardiac markers (atrial brain natriuretic peptide (BNP), sputum direct smear acid-fast staining, sputum tuberculosis DNA, general bacterial culture, electrocardiogram, blood routine and C-reactive protein, kidney function, electrolytes, myocardial enzyme profile, etc.
Liver function indicates a decrease in albumin 37.
4g/L (normal range 40-55g/L).

Pleural watercolor ultrasound: right pleural effusion (flaky fluid dark area in the right chest cavity, maximum anteroposterior diameter 9.
9 cm).

Pericardial ultrasound: a small amount of fluid
in the pericardial cavity.
Right thoracentesis + closed drainage was given, and direct smear acid-fast staining microscopy (sample: pleural fluid): acid-fast bacilli were not found; TB DNA test (sample: pleural effusion) was negative
.

Routine pleural fluid examination (sample: pleural effusion): yellow, no clotting, slightly turbid, positive Li Vanta test (+++), nucleated cell count 32.
8×106/L (transudate < 300, exudate > 500).

Biochemistry of pleural fluid (sample: pleural effusion): glucose 5.
42 mmol/L (reference interval 3.
6-5.
5), total protein 45.
4 g/L, amylase 53.
00 u/l, adenosine deaminase 133.
70 U/L, lactate dehydrogenase 276 U/L
.

Reviewing the patient's previous admission data, the patient's serum interferon release test was negative, acid-fast bacilli were not found in sputum and pleural fluid acid-fast staining, the DNA test for pleural fluid tuberculosis was negative (-), the culture of Mycobacterium sputum tuberculosis was negative, and the basis for tuberculosis diagnosis was insufficient
.

Serum respiratory tumor markers: tumor marker antigen 125: 146.
34 U/mL increased, cytokeratin 19 fragment: 8.
40ng/mL increased, late thoracentesis aspiration: thymus adenosine deaminase (ADA) 133.
70 U/L, lactate dehydrogenase (LDH) 276 U/ L (cancerous pleural fluid lactate dehydrogenase >200 U/L), further elevated
.

Fiber bronchoscopy tips: 1.
Right upper lobe occlusion; 2.
The right middle and lower lobe bronchial opening is severely narrowed, the flexible bronchoscope has not been able to penetrate, it is suspected that the lung mass makes the bronchi have signs of compression, and the sputum etiology is negative on the fiber bronchoscopic brush, and the diagnosis
of lung tumor cannot be ruled out.

Please consider after consultation with tuberculosis experts of Wuhan Jinyintan Hospital: proliferative pulmonary tuberculosis has been confirmed to have positive sputum tuberculosis DNA, tuberculous pleurisy, pericardial effusion, the possibility of lung tumor is not excluded, and it is recommended that patients undergo further examination of pleural fluid to check the fluid-based thin layer cell filming, and if necessary, pleural biopsy
.

2021.
10.
22: Pleural fluid-based thin-layer cell filming: (right pleural effusion) Centrifugal cell sediment paraffin section: A large number of lymphocytes are seen in red blood cells and fibrinous exudates, more tissue cells and epithelial-like cells arranged in glandular ducts, and the possibility of cancer is high! And immunohistochemistry AE1/AE3, Vimentin, CR, CK5/6, CK7, TTF-1, Ber-EP4, CD68 is required
.