A 73-year-old man with essential hypertension was referred to our hospital because of a 5-month history of persistent dyspnoea on exertion due to recurrent left-sided pleural effusion. The patient had been diagnosed with drug-sensitive pulmonary tuberculosis 5 years previously and was successfully treated with anti-tubercular therapy for 6 months. Before referral to our hospital, the initial workup was negative for tuberculosis, but anti-tubercular therapy was empirically re-initiated for 3 months because of suspicion of tuberculous pleurisy. The patient also underwent multiple thoracentesis procedures; however, the initial pleural fluid examination results were unavailable for review because the thoracentesis procedures were performed in another hospital. Because of the recurrent effusions, a left-sided tunnelled intrapleural catheter was placed for palliation, leading to mild symptom improvement and intermittent removal of pleural fluid. On arrival to our hospital, the pleural catheter had been removed, and the patient reported experiencing persistent dyspnoea on exertion and coughing.
Examination
On examination, the patient was afebrile and tachypnoeic, had normal blood pressure, regular heart rate and rhythm with a loud second pulmonary heart sound, and oxygen saturation of 90% on room air at rest. Jugular venous distension, peripheral oedema, and cyanosis were present without clubbing. Auscultation revealed diminished breath sounds with dullness on percussion in the lower two-thirds of the left hemithorax. The serum C-reactive protein concentration, erythrocyte sedimentation rate, autoimmune antibody levels, immunoglobulin G4 concentration, carcinoembryonic antigen concentration, and interferon-gamma release assay were all unremarkable.
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