A70-15 Atypical Presentation of Tuberculosis as Recurrent Pericardial Effusions Without Cough

Introduction Tuberculosis (TB) has been extensively studied and treated throughout human history. It most commonly presents with a chronic cough, either dry or productive, often with sputum or blood. Here, we present a patient who tested positive for tuberculosis without cough, instead presenting with recurrent pericarditis, pericardial effusions, and pleural effusions. Case A 40-year-old woman with hypertension and chronic kidney disease presented with two days of chest pain and shortness of breath. The pain was pleuritic and radiated to her left lateral rib. She also reported an eight-pound weight loss over two weeks but denied fever, chills, nausea, vomiting, abdominal pain, or cough. She had no recent travel or autoimmune disease. She grew up in Haiti and moved to California two years ago. Outside hospital records showed a CT angiogram with left pleural and moderate pericardial effusions.The patient had experienced similar symptoms twice in the previous year and had undergone pericardiocentesis for a large pericardial effusion of unknown etiology. She was lost to follow-up and had moved to Kansas one year prior to this admission.A bedside transthoracic echocardiogram showed a hyperdynamic left ventricle, preserved right ventricle function, and moderate pericardial effusion with septation but no right ventricular collapse. Chest X-ray demonstrated bilateral moderate pleural effusions. Thoracentesis was performed for diagnostic and therapeutic purposes. The initial pleural fluid culture was positive for acid-fast bacilli, suggesting tuberculosis; however, subsequent cultures and confirmatory testing by the Kansas Department of Health and Environment were negative. Thus, the diagnosis of TB remained uncertain.The patient underwent thoracotomy with pericardial window, resulting in significant relief of symptoms. She was started empirically on rifampin, isoniazid, pyrazinamide, ethambutol, and vitamin B6, and was discharged in stable condition with outpatient follow-up for continued treatment. Discussion Tuberculosis typically presents with cough, fever, weight loss, and chest pain, but symptoms vary with the site of infection. Extrapulmonary TB can present atypically, and diagnosis may be delayed if respiratory symptoms are absent. In this patient, recurrent pericardial effusions were the only manifestation, and TB was considered only after multiple recurrences despite a history of residence in an endemic region. This case highlights the importance of maintaining a broad differential diagnosis for recurrent pericardial and pleural effusions, including both infectious and noninfectious causes, particularly in patients with TB risk factors.