Ward Round - Non-resolving pleural effusion in a patient with HIV infection

A 33year-old man was admitted to the medical ward at Queen Elizabeth Central Hospital for evaluation of a pleural effusion that had progressed despite anti-bacterial and tuberculosis treatment.Eight months earlier he was diagnosed with sputum smear alcohol and acid-fast bacilli [AAFB] negative pulmonary tuberculosis.At that time his symptoms were fever, night sweats, cough and shortness of breath.The results of his initial chest X-ray are not known.He received standard tuberculosis treatment (rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months followed by rifampicin and isoniazid for four months).He stated that his symptoms improved during the first two months of tuberculosis treatment,but he then developed a pleural effusion that was tapped three times over the course of the four months prior to admission.Straw colored fluid was obtained twice but results of microbiological and biochemical analysis of the pleural fluid samples were not available.The last time a dry pleural tap was recorded.Courses of amoxicillin and chloramphenicol were given without improvement.Five days before admission he developed progressive complaints of productive cough with brownish sputum and shortness of breath on exertion.He had no constitutional symptoms.He was a lifetime non-smoker and had no exposure to asbestos or significant amounts of particulate matter.He was HIV positive with World Health Organization (WHO) clinical stage 3 disease (pulmonary TB) and a CD4 count of 187cell/μL.He had started antiretroviral therapy with stavudinelamivudine-nevirapine 14 weeks before admission along with cotrimoxazole prophylaxis.On examination he was well nourished and not in respiratory distress.Discrete, firm, non-tender lymph nodes, 1-2cm in diameter were found in the sub-mandibular area.His blood pressure was 120/80 mmHg, pulse rate 100/min, respiratory rate 26/min and temperature 37.5oC.The trachea was deviated to the right side.He had reduced chest expansion, stony dull percussion and reduced breath sounds as well as a few crepitations on the right side of the chest.The rest of the examination was normal.In particular, there were no signs of heart failure, ascites or Kaposi's sarcoma.Full blood count results were as follows: WBC = 9,300/μL (with normal differential count), Hb = 11.7 g/dL and platelet count of 346,000/μL.A chest X-ray (figure 1) taken shortly after admission, showed opacification of most of the right lung with mild apical sparing, suggestive of massive pleural effusion or extensive dense consolidation.The volume of the right hemithorax appeared to be reduced.A CT scan of the chest (figure 2) was made which was reported as follows: Right pleural fluid collection of 8 by 3cm with concentric pleural Ward Round -Non-resolving pleural effusion in a patient with HIV infection