Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report

Accelerated malignant hypertension frequently manifests as multiple organ dysfunctions. However, persistent symptoms despite appropriate antihypertensive therapy warrant investigation of concurrent pathologies, particularly in patients with risk factors for opportunistic infections. A 57-year-old woman with untreated hypertension presented in August 2024, with markedly elevated blood pressure (208/122 mmHg), systolic dysfunction (ejection fraction, 42.5%) and acute kidney injury (creatinine 4.74 mg/dl). Accelerated malignant hypertension with multiple organ damage was diagnosed based on these findings. Despite optimal antihypertensive and diuretic therapy, pleural effusion and renal function progressively worsened. Thoracentesis revealed a lymphocyte-predominant exudative effusion with elevated adenosine deaminase levels. Subsequent investigations confirmed tuberculous pleuritis and peritonitis, ultimately diagnosed as miliary tuberculosis. Excessive diuretic therapy for presumed heart failure-related effusion exacerbates renal injury. Following initiation of antituberculous therapy, pleural effusion and renal function markedly improved. This case emphasizes the importance of reevaluating initial diagnoses when the clinical responses are suboptimal. In patients with multiple risk factors, particularly diabetes mellitus and kidney dysfunction, concurrent tuberculosis should be considered for treatment-refractory symptoms.