Contarini syndrome due to tuberculous pleuritis and hepatic hydrothorax in a low-resource setting

Dear Editor, Bilateral pleural effusion most commonly results from congestive heart failure or malignancy; however, a subset of patients present with Contarini syndrome, defined as bilateral pleural effusions arising from different aetiologies and exhibiting distinct fluid characteristics in each hemithorax.1 This rare entity occurs in approximately 5% of patients with bilateral pleural effusion2 and is historically named after Francesco Contarini, whose terminal illness involved discordant pleural fluid characteristics.1,3 Recognition is clinically important because assuming a single aetiology may delay diagnosis, expose patients to unnecessary procedures and result in suboptimal therapy. A 50-year-old male with a history of substance use (abstinent for 2 years), intradomiciliary tuberculosis exposure and treated primary syphilis presented with 1 month of malaise, asthenia, adynamia, 5 kg weight loss, intermittent night sweats and occasional fever. Five days before admission, he developed dyspnoea on exertion and left lower limb oedema with localised warmth and claudication. Examination revealed blood pressure 90/60 mmHg, heart rate 102 bpm, respiratory rate 27 breaths/min, temperature 36.4°C, oxygen saturation 98% on room air and body mass inde×20.1 kg/m2. Laboratory testing demonstrated elevated D-dimer, hypoalbuminemia and mildly elevated lactate dehydrogenase. Computed tomography (CT) angiography identified subsegmental pulmonary embolism, bilateral pleural effusions and signs of chronic liver disease. Thoracic ultrasound demonstrated a simple non-septate right effusion yielding transudative fluid on thoracentesis, while the left hemithorax showed swirling sign, pleural thickening and exudative cytochemical characteristics. Adenosine deaminase measured 41 U/L and the interferon-gamma release assay was positive, prompting antituberculosis therapy. Ultrasound-guided pleural biopsy confirmed granulomatous pleuritis. Further evaluation revealed hepatitis C viremia consistent with hepatic hydrothorax. During follow-up, the left effusion resolved after treatment, whereas the right effusion remained refractory and required indwelling pleural catheter placement; the patient ultimately died from complications of cardiac and hepatic disease. This presentation highlights the diagnostic complexity of bilateral effusion when aetiologies differ. Although heart failure and malignancy predominate globally, the coexistence of tuberculous pleuritis and hepatic hydrothorax represents an uncommon combination requiring systematic evaluation. Sequential diagnostic algorithms have been proposed,4 yet clinical history, asymmetry in radiological appearance and discordant fluid analysis should prompt individualised investigation rather than assumption of a shared cause. In this case, integration of CT findings with thoracic ultrasound allowed early differentiation between effusions, informed targeted biopsy and facilitated identification of concurrent hepatic pathology. Regional epidemiology further influences interpretation. Whereas malignancy is often emphasised in high-income settings, tuberculosis remains prevalent in our environment, underscoring the importance of contextual clinical reasoning. Alarm features raising suspicion for discordant aetiologies include fever, pleuritic pain, asymmetry between hemithoraces and unilateral resolution during follow-up.1,5 Thoracic ultrasound provided superior characterisation of fluid morphology compared with tomography and served as a practical bedside tool to guide invasive decision-making. Bilateral pleural effusions should therefore not be presumed to share a single mechanism. A comprehensive evaluation integrating clinical context, imaging and laboratory data is essential. Recognition of Contarini syndrome reinforces the need for multidisciplinary assessment and highlights the diagnostic utility of ultrasound-guided evaluation, particularly in resource-constrained environments where efficient resource utilisation is critical. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.