A 22-year-old man with pleural tuberculosis associated hydropneumothorax: Case report and literature review

Abstract

A 22-year-old Asian male presented with fever, non-productive cough, right-sided pleuritic chest pain and was found to have a large right hydropneumothorax. A chest tube was placed. Pleural fluid analysis revealed a lymphocytic predominant exudate and he was subsequently started on four-drug daily anti-tuberculosis therapy (isoniazid, ethambutol, rifampin, pyrazinamide). Pleural biopsy revealed acid-fast bacilli. Given his persistent pleural effusion, he was given four doses of intrapleural tissue plasminogen activator (tPA) and dornase alpha (DNase) via his chest tube over a period of 6 days resulting in clinical and radiologic improvement. Pleural biopsy and pleural fluid culture specimens later revealed Mycobacterium tuberculosis. Intrapleural tPA-DNase therapy has demonstrated improved resolution of infections and shortened hospitalizations for parapneumonic infectious effusions. However, there is little literature on the use of intrapleural fibrinolytics specifically for pleural tuberculosis associated effusions. Furthermore, the American Thoracic Society does not comment on therapeutic thoracentesis or intrapleural fibrinolytic therapy in their recommendations for treatment of pleural tuberculosis. In our case of pleural TB-associated hydropneumothorax, the use of intrapleural tPA-DNase therapy facilitated pleural fluid drainage and resulted in near-complete resolution of the effusion.

Intrapleural alteplase and DNase for complex tuberculous pleurisy: a medical approach

“…Few studies reported on the use of intrapleural urokinase or streptokinase in tuberculous effusion to facilitate pleural fluid drainage and the occurrence of residual pleural thickening [8,11,12]. There is limited literature on the use of intrapleural alteplase (with supplementary DNase) in complex tuberculous pleurisy [13,14]. Our cases showed that intrapleural alteplase and DNase facilitated more infected fluid drainage with clinical resolution of fever and dyspnoea.…”

Non-traumatic Diaphragmatic Eventration With Extrapulmonary Tuberculosis Presenting As Pleural Effusion in an Indian Male: The First Report of Its Type

“…However, it's important to consider tuberculous pleural effusion in patients presenting with a predominantly lymphocyte-based exudative effusion. Determining the etiology of such effusions can be challenging and typically involves a combination of pleural fluid analysis and clinical correlation [ 5 , 12 ]. Adenosine deaminase (ADA) testing in pleural fluid can effectively rule out tuberculosis, especially in low-prevalence settings, and support diagnosis in high-prevalence areas with negative confirmatory tests [ 6 ].…”

“…Pleural tuberculosis is seldom reported, even in endemic countries [ 5 ]. Pleural tuberculosis develops in 3-5% of total tuberculosis patients worldwide, although in high-prevalence situations, this number could rise to 30% [ 6 ].…”

Cost-effectiveness of intrapleural use of tissue plasminogen activator and DNase in pleural infection: evidence from the MIST2 randomised controlled trial

“…Since publication of the MIST2 trial, there have been numerous case series of its use as both "rescue therapy" and as an alternative to surgery in selected patients, totalling over 500 patients to date. [11][12][13][14][15][16][17][18][19][20] However, the costs of t-PA and DNase given twice daily for 3 days (as per the MIST2 protocol) are considerable. 21 It is not as yet clear if these increased medication costs are offset by reductions in surgical referral and shortened length of hospital stay.…”