Abstract We report a case of a 45-year-old male with a remote history of pulmonary tuberculosis, successfully treated with 9 months of treatment and subsequent documentation of three negative AFB sputums. The patient presents with a one-month history of cough and weakness. His past medical history is significant for alcoholic cirrhosis, chronic Hepatitis B infection, hepatocellular carcinoma, and chronic pancytopenia. On presentation, imaging revealed a large loculated pleural effusion. A thoracentesis and pleural fluid analysis showed highly neutrophilic exudate with low pleural pH, glucose concerning empyema, and an elevated adenosine deaminase level of 40 U/L. Add-on PCR testing confirmed Mycobacterium tuberculosis infection. Given his prior treatment completion, origin from a region with high resistance rates (Equatorial Guinea), and disease recurrence, resistance testing was submitted to the Centers for Disease Control and Prevention for Molecular Detection of Drug Resistance (MDDR) to guide further therapy.Standard RIPE therapy was unable to be re-initiated due to elevated liver enzymes, likely secondary to underlying cirrhosis versus possible drug-induced hepatotoxicity. Instead, a modified regimen included levofloxacin 500 mg daily, ethambutol 1g daily, and subsequent gradual reintroduction of Rifampin 600 mg daily.This case highlights the variety in disease presentation of active tuberculosis. TB Pleuritis is commonly characterized as a delayed hypersensitivity reaction to presentation of bacilli in pleural fluid, and its low organism burden makes AFB culture and smear insensitive. Less commonly, direct pleural space infection can occur, resulting in tuberculous empyema, which is a pathophysiologically distinct entity characterized by neutrophilic inflammation, high bacillary load, and frequent fibrothorax formation. In this case, PCR testing was instrumental in confirming the diagnosis, suggesting a potential role for routine M. tuberculosis PCR testing in pleural fluid evaluation, particularly when TB-associated empyema is suspected. This abstract is funded by: None
Rezaee et al. (Fri,) studied this question.