Multidrug-Resistant Moderate Tubercular Pleural Effusion: A Rare Case Presentation

Area of Science:

• Pulmonology
• Infectious Diseases
• Medical Case Reports

Background:

• Drug-resistant tuberculosis (DR-TB) poses a significant global health challenge, particularly in developing regions.
• Extra-pulmonary tuberculosis, especially pleural effusion, presents diagnostic difficulties due to low bacterial loads and inconsistent Ziehl-Neelsen staining.
• Multidrug-resistant tuberculosis (MDR-TB) is defined by resistance to isoniazid and rifampicin, the most potent anti-TB drugs.

Observation:

• A 60-year-old male presented with symptoms including breathlessness, cough, weight loss, chest pain, and fever.
• Pleural fluid analysis revealed exudative effusion (Light's criteria) with positive adenosine deaminase (ADA).
• Cartridge-based nucleic acid amplification test (CBNAAT) and line probe assays (LPAs) identified Mycobacterium tuberculosis (MTB) with resistance to rifampicin and isoniazid.

Findings:

• The patient received an oral regimen including bedaquiline, adhering to World Health Organization (WHO) guidelines.
• The customized treatment led to significant clinical improvement.
• Early and comprehensive investigations, including Xpert MTB/RIF, culturing, and genotype drug sensitivity testing (DST), are vital for DR-TB management.

Implications:

• This case underscores the importance of prompt and accurate diagnosis of DR-TB in pleural effusions.
• Timely application of molecular diagnostic tools and appropriate drug regimens can effectively manage complex DR-TB cases.
• The findings highlight the need for early pleural fluid and biopsy investigations to guide treatment decisions in suspected DR-TB pleural effusions.