A 35-year old man with a non-resolving pleural effusion.

ABSTRACT

A thirty-five-year old male, a nonsmoker, was referred to us for evaluation of progressive pulmonary disease. His clinical course during the past 2 years was characterized by paroxysmal attacks of cough with scanty mucoid sputum. This was accompanied by intermittent fever and malaise. There was no history of wheezing, nasal symptoms or loss of weight. Eighteen months prior to referral, based on his symptomatic and roentgenologic profile, he was clinically diagnosed as a case of tuberculous mediastinal lymphadenitis. He was initiated on antituberculous therapy (ATT) comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 800 mg once daily. Prednisolone (10 mg thrice daily) was added after 2 months when the patient did not experience any relief. He was however irregular with the oral steroids and stopped it after 1 month. One year prior to referral, while on ATT for 6 months, he had few episodes of blood-streaked sputum, episodic exertional dyspnoea, and rightsided chest pain that increased on coughing and deep breathing. This was diagnosed as right-sided pleural effusion, and the patient was initiated on second line ATT in the form of kanamycin 1gm intramuscularly, sparfloxacin 400 mg, prothionamide 750 mg, clofazamine 200 mg, clarithromycin 500 mg, thiacetazone 150 mg and isoniazid 300 mg once daily. Kanamycin was stopped after 6 months but the other drugs were continued for a period of 1 year. In spite of regular second line ATT for 1 year, the patient remained symptomatic and as the effusion persisted, he was referred to us for evaluation. Physical examination revealed a middle-aged male in no acute distress. There was no clubbing or cyanosis. Chest examination suggested a right-sided pleural effusion. Examination of other systems, including an ophthalmologic referral, did not detect any abnormality.