A Complicated Course of Pulmonary Tuberculosis With Cavitary Findings and Pleural Effusion

This report describes the case of a 39-year-old male who recently immigrated from Ecuador and presented with recurrent fevers, pleuritic chest pain, and progressive respiratory symptoms initially treated as community-acquired pneumonia. Despite empiric antibiotic therapy, the patient experienced clinical deterioration with rapid accumulation of a left-sided pleural effusion and imaging evidence of a cavitary lung lesion. Pleural fluid analysis demonstrated a lymphocyte-predominant exudative effusion with elevated adenosine deaminase levels, raising suspicion for tuberculous pleuritis despite repeatedly negative acid-fast bacilli smears and cultures, a well-recognized limitation in tuberculous pleuritis given the paucibacillary burden and slow growth of Mycobacterium tuberculosis. Definitive diagnosis was established via video-assisted thoracoscopic surgery, with pleural biopsy revealing caseating granulomas consistent with tuberculosis (TB), with the clinical course further complicated by methicillin-resistant Staphylococcus aureus empyema. The patient was successfully treated with surgical drainage and guideline-directed anti-tuberculous therapy, resulting in clinical improvement. This case underscores the diagnostic challenges of extrapulmonary TB in non-endemic regions and highlights the importance of maintaining a high index of suspicion in patients from endemic areas, even when initial microbiologic testing is negative.