Thoracoscopic crush biopsy unmasking drug resistant extrapulmonary tuberculosis

Tuberculosis remains a major global health concern with extrapulmonary manifestations contributing to approximately 15-20% of cases in immune-competent hosts. In 2022, National Tuberculosis Elimination Program (NTEP) reported multidrug resistance in 2.5% of new tuberculosis cases and 13% in previously treated cases. Among extrapulmonary tuberculosis pleural tuberculosis is one of the most common forms. It becomes a diagnostic challenge when microbiological tests are inconclusive. In most developing countries, antitubercular drugs are initiated empirically in patients on the basis of clinical decision. In today's day and age, physicians emphasize more on evidence-based medicine practice. We report a case of a young man who presented with exudative pleural effusion unresponsive to empirical antibiotics. Thoracoscopic pleural crush biopsy showed granulomatous inflammation with caseating necrosis and acid-fast bacilli, confirming tuberculous pleuritis that was multidrug resistant. This case illustrates the role of medical thoracoscopy in patients where suspicions for tuberculosis are raised without clear answers from the initial tests. Relying only on standard antitubercular treatment may delay the detection of underlying drug resistance that is a growing public health challenge. Early tissue diagnosis through thoracoscopy allowed timely identification of multidrug resistance and directed proper management.