Jawed Abubaker, Mariam Akram.
A young man with fever and abdominal pain..
Infect Dis J Jan ;13(4):106-9.

A 20 year old young man presented with high grade fever (103-1040F) for last five days with right sided abdominal pain. On examination he was unable to take a deep breath because of pain, there was no positive finding on the rest of the abdominal exam. This patient had abdominal ultrasound performed which demonstrated moderate right sided pleural effusion and the rest of the exam was normal. Patient was started on broad spectrum antibiotics after CBC and diagnostic pleurocentesis performed as an out patient. The pleural fluid analysis demonstrated : Protein 5 Gm/L, LDH 450 IU, Pleural fluid cell count: neutrophils 47%, lymphocytes 46%, many mesothelial cells. At follow up visit after two days; he was still febrile but feeling a little better with adequate pain relief. He was the hospitalized and I/v antibiotics were started. At this stage of patient`s illness, although with exudative effusion and high grade fever, acute community acquired pneumonia with parapneuomonic effusion is the most plausible diagnosis but a few things are atypical for this presentation. He presented with symptoms suggestive of pleuritis without any cough, sputum production antecedent to the pain. With high grade fever and moderate exudative effusion his TLC count is not elevated also the chest X-ray does not demonstrate any underlying consolidation so alternate diagnosis must be considered, including acute tuberculous pleuritis. Pleural biopsy demonstrated caseous necrosis. AFB smear was negative and PCR for mycobacterium Tuberculosis was positive. Diagnosis of acute tuberculous pleuritis was made and he was started on standard four drug anti-tuberculous treatment.

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