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ISSN: Print -2349-0977, Online - 2349-4387


 
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CASE IN POINT - CLINICS IN PULMONOLOGY
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 104-106

Flummoxing paradox of contralateral pleural effusion developing during successful drug treatment of a tubercular pleural effusion


Department of Pulmonary, Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication30-Dec-2016

Correspondence Address:
Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.197216

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  Abstract 

Tuberculosis often manifests as pleural effusion which generally shows clinical and radiological response to antitubercular therapy. However, it is not common to find a paradoxical contralateral effusion to develop despite successful therapy, especially in immuno competent treatment responsive patients with no other etiology of the same. We report such a rare case in which the patient presented with left-sided pleural effusion, which resolved with treatment, only to follow-up with massive right-sided pleural effusion which resolved spontaneously on continuation of antitubercular therapy.

Keywords: Paradoxical, pleural effusion, self-resolution


How to cite this article:
Ish P, Chakrabarti S, Bhattacharya D. Flummoxing paradox of contralateral pleural effusion developing during successful drug treatment of a tubercular pleural effusion. Astrocyte 2016;3:104-6

How to cite this URL:
Ish P, Chakrabarti S, Bhattacharya D. Flummoxing paradox of contralateral pleural effusion developing during successful drug treatment of a tubercular pleural effusion. Astrocyte [serial online] 2016 [cited 2019 Jun 15];3:104-6. Available from: http://www.astrocyte.in/text.asp?2016/3/2/104/197216


  Introduction Top


Tubercular pleural effusion is one of the most common extrapulmonary manifestations of tuberculosis in addition to tubercular lymphadenopathy, which is often diagnosed on clinical and pleural fluid analysis and treated with standard antitubercular therapy (ATT). A paradoxical response [1] despite successful antitubercular chemotherapyhas been reported in cases of tubercular lymphadenopathy [2] and cerebral tuberculomas, however, rarely in cases of pleural effusion. [3],[4],[5] Moreover, this paradoxical response has been documented to occur 3-4 weeks after the start of ATT. [6] We report a case with contralateral paradoxical pleural effusiondeveloping after 2 months of successful ATT.


  Case Report Top


A 20-year-old young girl presented to the respiratory clinic of the hospital with complaints of fever for 2months, breathlessness for 1month, and left-sided chest pain for 15 days. The patient had no history of abdominal distension, neck swelling, weight loss, or any other systemic complaint. She had no history of tuberculosis.

On examination, patient had mild pallor, no icterus, lymphadenopathy, and pedal edema. On systemic examination, there were absent breath sounds on the left side with a dull percussion note. Chest X-ray revealed a left-sided moderate pleural effusion, which was tapped [Figure 1].
Figure 1: Chest X-ray showing a large left-sided pleural effusion with normal right lung

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Pleural fluid was straw colored, revealing lymphocytic predominance with low sugar and high adenosine deaminase (ADA) levels [Table 1]. A contrast-enhanced computed tomography (CT) of the chest was suggestive of massive left-sided pleural effusion [Figure 2]. Lung window was essentially normal and there was no evidence of ascites or disseminated tuberculosis. Mantoux test reading was 18 mm. Patient was started on standard ATT with 4 drugs, namelyisoniazid, rifampicin, pyrazinamide, and ethambutol with pyridoxine.
Figure 2: Contrast-enhanced CT of the chest showing normal right lung parenchyma and massive left-sided pleural effusion

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Table 1: Pleural Fluid Biochemical Analysis


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After 1 week, the patient was afebrile with increased appetite and feeling of wellbeing. Pleural effusion also decreased; after 1 month of therapy, patient had no evidence of residual effusion in eitherX-ray or ultrasound.

However, the patient presented subsequently with complaints of worsening breathlessness and right-sided chest pain. X-ray of the chest revealed a massive right-sided pleural effusion[Figure 3]. On a diagnostic tap, it was suggestive of a lymphocytic predominant exudative effusion with borderline ADA [Table 1].

Patient was further investigated and found to be antinuclear antibody (ANA) negative, negative for human immunodeficiency virus (HIV) by enzyme-linked immunosorbent assay (ELISA) done twice, and negative for malignant cytology in pleural fluid.
Figure 3: Chest X-ray showing paradoxical right-sided pleural effusion despite anti-tubercular therapy

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Because there was no evidence of any fever or any other systemic complaints, or any other cause of effusion, the patient was continued on antitubercular therapy while other causes of effusion were being evaluated. The effusion resolved after 1 month of continuation of therapy [Figure 4].
Figure 4: Chest X-ray showing resolution of pleural effusion on continuation of antitubercular therapy

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  Discussion Top


Formation of a new lesion during successful antitubercular chemotherapy is often referred to as a paradoxical response. [1] This response has been reported often in cases of tubercular lymphadenopathy, however, has been rarely seen in pleural effusion. In our patient, such a response was observed after 2 months of successful therapy after resolution of the original effusion.

A large study of 458 patients with pleural tuberculosis found paradoxical response in 16% of the patients, but majority were worsening of the same-sided effusion; [7] however, in our case, the response was on the opposite side.

The most commonly documented explanation is the paradoxical immune activation, especially in HIV infected patients. In non-HIV infected patients, treatment failure, drug resistance, and paradoxical mechanisms have been suggested. [5] Hematogenous dissemination, rupture of caseous lymph nodes or subpleural abscesses into the pleural space, and immunological rebound after treatmenthave been reported as the probable mechanisms. [1],[4],[8] Drugs such asisoniazid arewell-known to induce lupus, although the reported cases are rare. An elevated level of ANA is found in lupus pleuritic. [6] Paradoxical IRIS occurring in HIV patients has also been reported to present with tubercular lymphadenopathy and rarely effusion.

In our patient, tests for HIV and lupus were negative. She had no resurgence of fever and did not reveal any alternativediagnosis. More importantly, the paradoxical effusion resolved and required no additional or alternate treatment.


  Conclusion Top


This case highlights the uncommon phenomenon of paradoxical response and attempts to stress on the recognition, understanding, and deciphering the complex and multiple etiopathologies of this manifestation. There are no current guidelines on the management of such complications and the role of steroids is also equivocal. [5] Further studies are required for a better understanding of this phenomenon, however, currently it can be safely concluded that the development of contralateral pleural effusion during the treatment for tuberculous effusion in immunocompetent patients is rare, which resolves with continuation of therapy in the absence of an alternate etiology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Smith H. Pradoxical responses during the chemotherapy of tuberculosis. J Infect 1987;15:1-3.  Back to cited text no. 1
    
2.
Chambers ST, Hendrickse WA, Record C, Rudge P, Smith Hillas. Paradoxical expansion of intracranial tuberculoma during chemotherapy. Lancet 1984;2:181-4.  Back to cited text no. 2
    
3.
Al Majed SA. Study of paradoxical responses to chemotherapy in tuberculous pleural effusion. Respir Med 1996;90:211-4.  Back to cited text no. 3
    
4.
Corral-Gudino L, Rivas-Lamazares A, González-Fernández A, Hernando-García JC. Paradoxical deterioration during antituberculous therapy in non-HIV-infected patients with pleural tuberculosis: Apragmatic approach. Eur J Case Rep Intern Med2016;3.  Back to cited text no. 4
    
5.
Hiraoka K, Ngata N, Kawajiri T, Suzuki K, Kurokawa S, Kido M, et al. Paradoxical response to anti-tuberculous chemotherapy and Isoniazid induced lupus.Respiration1998;65:152-5.  Back to cited text no. 5
    
6.
Vilaseca J, Lopez-Vivancos J, Arnau J, Guardia J. Contralateral pleural effusion during chemotherapy for tuberculous pleurisy. Tubercle 1984;65:209-10.  Back to cited text no. 6
    
7.
Jeon K, Choi WI, An JS, Lim SY, Kim WJ, Park GM, et al. Paradoxical response in HIV-negative patients with pleural tuberculosis: Aretrospective multicentre study. Int J Tuberc Lung Dis 2012;16:846-51.  Back to cited text no. 7
    
8.
Onwubalili JK, Scott GM, Smith H. Acute respiratory distress related to chemotherapy of advanced pulmonary tuberculosis: A study of two cases and review of the literature. Q J Med 1986;59:599-610.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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