Pathological Case of the Month FREE

A 16-YEAR-OLD GIRL was seen for fever, headache, malaise, and right-sided chest wall pain of 1 week's duration. Prior to presentation, she developed a dry cough and nighttime sweating. On admission, her temperature was 38.8°C; pulse, 100 bpm; respirations, 20 breaths per minute; blood pressure, 114/75 mm Hg; and oxygen saturation, 95% breathing room air. She had dullness to percussion and decreased breath sounds over the lower 2/3 of the right posterior lung field. Upright and decubitus chest radiographs showed a free-flowing pleural effusion occupying 3/4 of her right lung field. Further questioning revealed she had emigrated to the United States from Haiti 4 months earlier and had negative findings on purified protein derivative (PPD) testing 3 months earlier. Her white blood cell count was 6800/µL (64% neutrophils, 3% bands, 17% lymphocytes, and 16% monocytes). Values for hematocrit and platelet count were normal; serum total protein, 7.4 g/dL; serum lactate dehydrogenase (LDH), 578 U/L.

She underwent thoracoscopy and chest tube placement; 800 mL of serosanguinous fluid was drained. During thoracoscopy, 2- to 3-mm white lesions studding the pleura with occasional larger outgrowths were noted (Figure 1). A view toward the apex demonstrated similar lesions, and visceral pleura was adhesed to parietal pleura at the apex (Figure 2). Histopathologic findings of the pleural biopsy specimen showed chronic inflammation and caseating granulomas (Figure 3). Pleural fluid findings included pH 7.44; LDH, 743 U/L; glucose, 95 mg/dL (5.3 mmol/L); protein, 5.7 g/dL; red blood cell count, 9050/µL, and white blood cell count, 1740/µL (11% neutrophils, 81% lymphocytes, and 8% mononuclear histiocytes). Findings from gram stain of pleural fluid and Kinyoun stains of pleural fluid, pleural tissues, and sputum were negative for organisms. Routine bacterial culture of pleural fluid, pleural tissue, and blood; fungal culture of pleural fluid; and mycobacterial cultures of pleural fluid and pleural tissue were analyzed. A PPD test was placed.