A 34-year-old man comes to the emergency department due to 3 weeks of nonproductive cough, increasing shortness of breath, subjective fevers, night sweats, and intermittent right-sided, sharp chest pain. Two weeks ago, the patient was diagnosed with community-acquired pneumonia at an urgent care clinic and received a week of oral antibiotics without symptomatic improvement. He has no other medical problems and takes no medications. The patient has a history of injection drug use and was recently incarcerated. Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, and pulse is 88/min. Chest examination reveals decreased breath sounds and dullness to percussion in the right lower chest. Heart sounds are normal and without murmurs. The abdomen is soft and non-tender with no hepatosplenomegaly. He has no skin rash or enlarged lymph nodes. Chest imaging reveals a right lower lobe pulmonary infiltrate and moderate-sized pleural effusion. A thoracentesis is performed; the pleural fluid is lymphocyte predominant and exudative with an elevated adenosine deaminase level. No organisms are seen on smear. Rapid HIV testing is positive. Which of the following is the best next step in management of this patient's pleural effusion?

Question

A 34-year-old man comes to the emergency department due to 3 weeks of nonproductive cough, increasing shortness of breath, subjective fevers, night sweats, and intermittent right-sided, sharp chest pain.  Two weeks ago, the patient was diagnosed with community-acquired pneumonia at an urgent care clinic and received a week of oral antibiotics without symptomatic improvement.  He has no other medical problems and takes no medications.  The patient has a history of injection drug use and was recently incarcerated.  Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, and pulse is 88/min.  Chest examination reveals decreased breath sounds and dullness to percussion in the right lower chest.  Heart sounds are normal and without murmurs.  The abdomen is soft and non-tender with no hepatosplenomegaly.  He has no skin rash or enlarged lymph nodes.  Chest imaging reveals a right lower lobe pulmonary infiltrate and moderate-sized pleural effusion.  A thoracentesis is performed; the pleural fluid is lymphocyte predominant and exudative with an elevated adenosine deaminase level.  No organisms are seen on smear.  Rapid HIV testing is positive.  Which of the following is the best next step in management of this patient's pleural effusion?

Quizplus · Accepted Answer

Explanation: This patient with newly diagnosed HIV and recent incarceration has pleural effusion findings that suggest a tuberculous pleural effusion. HIV dramatically increases the risk for acquiring Mycobacterium tuberculosis and reactivating latent disease. Patients with higher CD4 counts who develop active pulmonary tuberculosis (TB) typically manifest apical, cavitary disease. However, those with advanced HIV usually cannot mount sufficient cell-mediated defenses to create cavitations and often present with lobar, pleural, or disseminated infection. Tuberculous effusions usually present with fever, cough, pleurisy, and weight loss. Thoracentesis typically reveals a lymphocyte-predominant, exudative effusion. Although malignancy may present with similar findings, an elevated adenosine deaminase level strongly suggests TB. As tuberculous pleural effusions are caused by a hypersensitivity reaction to M tuberculosis or its antigens, pleural fluid smear is usually aseptic (unlike tuberculous empyemas) and pleural biopsy is often required for diagnosis. (Choice A) This patient requires a definitive diagnosis for his pulmonary infection prior to the consideration of antiretroviral therapy (ART). ART is often delayed for 1-2 weeks after initiating tuberculosis treatment to reduce the risk of immune reconstitution inflammatory syndrome. (Choice B) Pneumocystis pneumonia is common in patients with AIDS and typically causes indolent fever, dyspnea, dry cough, and bilateral, interstitial infiltrates. Lobar infiltrate and pleural effusion are rare. In addition, Pneumocystis pneumonia is initially evaluated with induced sputum samples; bronchoalveolar lavage is the second-line diagnostic test. (Choice C) Most respiratory pathogens that result in a lobar infiltrate and parapneumonic effusion will cause acute (not subacute) symptoms and neutrophil-predominant (not lymphocyte-predominant) pleural fluid. This patient had no improvement with antibiotic therapy for community-acquired pneumonia and likely has TB. (Choice E) Histoplasmosis is an opportunistic infection in patients with HIV and usually presents as a febrile, wasting illness marked by fever, fatigue, weight loss, vomiting, and dyspnea. Chest radiograph is typically normal or reveals diffuse interstitial infiltrate; focal infiltrate and pleural effusion are rare. Educational objective: Patients with HIV are at higher risk for active tuberculosis. Cavitary, apical lung disease is common at higher CD4 counts, but patients with advanced HIV are at greater risk for lobar, pleural, or disseminated disease. Tuberculosis pleural effusions are typically lymphocytic and exudative with an elevated adenosine deaminase level. Smears are often negative for acid-fast bacilli; diagnosis usually requires pleural biopsy with histopathologic demonstration of pleural granulomas.

A 34-Year-Old Man Comes to the Emergency Department Due to 3