Organizing Pleuritis Presenting as Recurrent Lymphocyte Predominant, Exudative Effusion

Long-standing pleural effusions may rarely progress to pleural fibrosis, and when no identifiable etiology is present, this entity is termed cryptogenic fibrosing pleuritis (also referred to as organizing pleuritis, fibrous pleurisy, or fibrosing pleurisy). This condition is characterized by persistent exudative effusions and progressive pleural thickening, often leading to diagnostic uncertainty and therapeutic challenges. Due to its rarity, only a limited number of cases have been described in the literature, and an evidence-based management strategy has yet to be established. Reported treatments have included glucocorticoids and surgical decortication, with variable success and unclear long-term benefits. The authors have presented the case of an older man with recurrent unilateral lymphocytic exudative pleural effusion, extensive occupational asbestos exposure, and imaging findings concerning for pleural disease, in whom repeated thoracenteses failed to provide durable resolution. Given concern for an underlying malignant process, medical thoracoscopy was pursued, allowing direct pleural visualization and diagnostic biopsy. Histopathology confirmed organizing pleuritis without malignancy. Rapid protocol pleurodesis and placement of a tunneled pleural catheter were performed simultaneously. This case highlighted the diagnostic value and therapeutic potential of thoracoscopy combined with pleural drainage strategies as a less invasive alternative to surgical decortication in carefully selected patients with cryptogenic fibrosing pleuritis.