An 81-year-old man with a history of chronic atrial fibrillation came to our hospital with progressive dyspnoea of 2 months' duration, accompanied by asthenia and unquantified weight loss. The patient was afebrile, with semiology of right pleural effusion. Chest X-ray confirmed pleural effusion and mediastinal enlargement without lung parenchymal involvement. Blood tests were normal. Thoracentesis showed thick milky fluid with 1400 leukocytes/mm3 with 10% neutrophils and 90% lymphocytes, protein 49 g/L (pleuroplasmic ratio: 0.66), LDH 262 U/L (pleuroplasmic ratio: 0.75), glucose 10.2 mmol/L, ADA 16 U/L, cholesterol 1.75 mmol/L and triglycerides 12.8 mmol/L. Cytology and conventional culture were negative. Intradermal Mantoux test was negative.
Fibrobronchoscopy showed no endobronchial lesions. Ziehl-Neelsen staining and Löwenstein-Jensen medium culture of bronchoalveolar lavage were negative. A thoracoabdominal CT scan showed multiple adenopathic masses in the mediastinum and bilateral right predominant pleural effusion. A CT-guided fine needle puncture-aspiration of the mediastinal mass was performed, without being able to collect adenopathic tissue. Thoracoscopy with pleural and lung biopsy and placement of a pleural drainage tube was performed. Pathology showed chronic granulomatous lesions compatible with tuberculosis in both pleura and lung. PCR for Mycobacterium tuberculosis was positive in the lung biopsy and negative in the pleura. Treatment was started with Isoniazid 300 mg/day, Rifampicin 600 mg/day and Pyrazinamide 1250 mg/day. Despite the treatment, the patient presented a clinical worsening and respiratory failure, and died. A necropsy was performed, which revealed bilateral chylothorax, chronic granulomatous caseating lymphadenitis compatible with tuberculosis of mediastinal lymph nodes and bilateral pleuropulmonary, hepatic, left adrenal and renal miliary dissemination.
