The case refers to a 55-year-old patient with apparent good nutritional status, weighing 65 kg, of nursing profession, who consulted for a clinical picture of two weeks of dyspnea consisting of asthenia, adynamia in pleuritis 40
Vital signs at admission were as follows: blood pressure 130 to 80 mm Hg, heart rate of 106 beats per minute, respiratory rate of 20 breaths per minute, and third left lung hypoventilation baseline in two parts.
On admission laboratory tests, the following results were obtained: leukocytes, 7,950 per mm 3; neutrophils, 74 %; lymphocytes, 17 %, platelets, 751,000 per mm 3; hemoglobin, 11.5 g/dl 192 mg reactive creatinine; protein
Chest X-ray showed global cardiomegaly with mild aortic elongation and bilateral free pleural effusion, predominantly left, which shifted to the terminal half of the ca in the right lateral decubitus position.
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It was initially considered a community-acquired pneumonia and antibiotic treatment with ampicillin, sulfonamide and clarithromycin was initiated.
The results of the hemocultive and urocultive were negative and the evolution of the patient was torpid, with a tendency to worsening; for this reason, a left pleural effusion was practiced in approximately 300 ml guided by ultrasound.
As for the effusion on the left side, it was accompanied by underlying passive atelectasis and a volume of approximately 1,000 ml was calculated.
As an incidental finding, a moderate pericardial effusion was observed with echoes and septums inside, reaching the apex, with an anteroposterior diameter of up to 2.6 cm.
In the cytochemical analysis of the toracentesis product, it was reported: 1728 leukocytes per mm 3, 52 % neutrophils, 44 % lymphocytes; glucose of 105 mg/dl normal ventricular diastolic dysfunction; left ventricular septal dysfunction, 170 x cardiac hypertrophy, cardiac hypertrophy
The patient continued with fever and dyspnea.
A new measurement of C-reactive protein was 237 mg/dl, blood count was normal, creatinine was 1.2 mg/dl, polycultures yielded negative results, as well as pleural Ziehl-N staining.
Also, rheumatologic tests were requested, with the following results: C3, 166.5 mg/dl; C4, 46.3 mg/dl; IgA, 467 mg/dl; left ventricular ejection fraction LVEF, 83.7 dl.
It was considered the possibility of a tubercle infection, given the epidemiological nexus for his work in the health area, for which he was made a tuberculin test that reported a value of 23 mm latent tuberculosis institution.
Based on this new finding and on the clinical picture, it was decided to perform a new toracentesis and to perform a biopsy using a peri-existing window.
The pleural cytochemical analysis was very similar to the initial one, the adenosine deaminase (ADA) test was 30 IU/Muddh, in the pericardium biopsy seven weeks diffuse inflammation with no granulomas was reported.
It was decided to start treatment with rifampicin, isoniazid, pyrazinamide and etomidate without steroids, with which the patient presented a remarkable clinical improvement, until the complete resolution of her clinical picture.
