An 81-year-old man with a history of chronic atrial fibrillation was admitted to our hospital with a 2-month history of progressive dyspnea, accompanied by asthenia and unquantified weight loss.
The patient was afflicted with semiology of right pleural effusion.
The chest X-ray confirmed pleural effusion and mediastinal widening without pulmonary parenchymal involvement.
Blood tests were normal.
Elevated ALT, AST, alkaline phosphatase, elevated ALT, AST, alkaline phosphatase
Mantoux intradermal reaction was negative.
Fiberoptic bronchoscopy showed no endobronchial lesions.
Ziehl-Neelsen staining and culture of bronchoalveolar lavage fluid in Löstein-Jensen medium were negative.
A CT scan revealed multiple adenopathic masses in the mediastinum and bilateral pleural effusion of right predominance.
A CT-guided aspiration puncture of the mediastinal mass was performed, without being able to collect samples of adenopatic tissue.
Endoscopy was then performed with pleural and pulmonary biopsy, and a pleural drainage tube was placed.
Pathology showed chronic granulomatous lesions compatible with tuberculosis both in lung and in lung.
PCR for Mycobacterium tuberculosis was positive in lung biopsy and negative in culture.
Treatment was initiated with Isoniazid 300 mg/day, Rifampicin 600 mg/day and Pirazinamide 1250 mg/day.
Despite treatment, the patient presented clinical worsening and respiratory failure, with exitus.
Necropsy revealed bilateral chylothorax, caseifying granulomatous chronic lymphadenitis compatible with tuberculosis of mediastinal lymph nodes and bilateral pleuropulmonary, hepatic, left adrenal and renal miliary dissemination.
