Middle aged female with pleural effusion - A Double Whammy 

D. Bhatkar^a (Dr), N. Vennilavan^a (Dr), GS. Grace^a (Dr), U. Bhattu^a (Dr), A. Ingle^a (Dr), V. Balasubramanian*^a (Dr)

^a Yashoda Hospitals, Hyderabad, INDIA

* drviswes89@gmail.com

Background:

Lupus pleuiritis can occur as the initial clinical presentation and is reported only in 2-3% of patients with SLE. Though patients with SLE can develop tubercular pleural effusion due to underlying immunosuppression induced by the disease or drugs used in treatment, coexistent lupus nephritis with tubercular pleural effusion is extremely uncommon.

Case Report:

A 40 year old female with coexistent hypertension and hypothyroidism was treated as seronegative rheumatoid arthritis for 1 year with steroids and methotrexate at an outside hospital. On presentation patient reported low grade fever, loss of weight and appetite for 15 days. On physical examination, gangrene of right toe and anasarca was observed.CT Chest was suggestive of left sided pleural effusion with subcarinal lymphadenopathy. Serology tested positive for ANA and Anti-ds DNA confirming the diagnosis of SLE. Urine analysis revealed proteinuria: 3+ and pleural fluid cytology showed LE cells and analysis was suggestive of haemorrhagic exudative lymphocytic effusion with low ADA confirming lupus pleuritis. Since effusion was unilateral and rheumatologist was keen to initiate the patient on pulse steroid and immunomodulators, a decision for thoracoscopic biopsy was made to rule out secondary infection. Thoracoscopy was suggestive of inflammed pleura and biopsy revealed granulomatous inflammation with stain for AFB positive, confirming a diagnosis of coexistent lupus pleuritis and tubercular pleural effusion. Patient was initiated on standard ATT and oral steroids and following 2 weeks of treatment with ATT, pulse steroids and rituximab was initiated. At 6 month followup patient had significant resolution of effusion and remission of SLE was achieved.

Conclusion:

To the best of our knowledge, this is the first case report of pathology proven ipsilateral coexistent lupus pleuritis with tubercular effusion. Prompt identification and management of coexistent tuberculosis is important to avoid dissemination of tuberculosis on the background of immunosuppression to mitigate morbidity.

Disclosure of funding source(s): none