22/04/2025
A case of Disseminated TB
Key Words: EPTB diagnostic challenge, therapeutic challenge, Thoracoscopy, Pleural biopsy, Pleural tissue Gene Xpert
Case: A 35-year-old, nondiabetic, normotensive lady presented to us with the complaints of respiratory distress for last 1 month, which became more severe for last 5 days. She also complained localized dorsal back pain for same duration. No H/O cough, hemoptysis, fever, anorexia, weight loss. She also denied any weakness, numbness, paresthesia of legs, any lumps or bumps in any site.
Following examination, we found features of right sided pleural effusion and a small tender swelling over dorsal spine consistent with gibbus without any evidence of myelopathy.
Initial lab work-up revealed left sided encysted pleural effusion. Pleural fluid analysis revealed exudative, Neutrophil 90%, ADA 150 U/L consistent with empyema. We also found features of tubercular spondylodiscitis from D6 to D11 vertebral level without any evidence of paravertebral soft tissue collection.
We did a thoracoscopy and found moderate straw-colored pleural fluid along with many septations within the pleural space and areas of irregular pleural thickening. Accessible septa were removed by a semi-rigid thoracoscope and biopsy from parietal pleura was taken and sent for Gene Xpert and histopathology (HPE). Gene Xpert from pleural tissue became positive and the HPE result was also consistent with TB. Due to financial hardship of the patient, we minimized further evaluation.
We diagnosed her a case of Disseminated TB (Pleura, Spine), started anti-TB medications along with consultation from neurosurgical team. Advice was to continue medical management.
Patient was on regular follow-up with significant improvements of clinical symptoms along with chest and spine imaging. Currently she is continuing anti-TB (9th month), with a plan to complete 12 months of anti-TB. Up to now no complication related to the management was observed. Relevant images were attached after taking consent from the patient.
Discussion and learning points: As we know definitive diagnosis of EPTB, specially disseminated TB is often difficult due to lack of the facility for taking adequate specimen for microbiological or tissue diagnosis. Here we could have done an FNAC from the spinal lesion for cytological and microbiological diagnosis. Rather we went for thoracoscopy and pleural tissue biopsy. As our patient had encysted pleural effusion, she needed a chest intervention. With a single setting we provided the necessary pleural management as well as took adequate specimen for making a definitive diagnosis and here lies the beauty of intervention pulmonology.
