Pleural Effusion and Fever in an Immunocompromised Patient.

A 15-year-old female with a past medical history significant for autoimmune hepatitis on chronic immunosuppressive medications presented to a community hospital with a 24-hour history of shortness of breath, right-sided pleuritic pain, cough, fever, and headache. Review of systems was otherwise negative. She was diagnosed with pneumonia and admitted for empiric treatment with ceftriaxone, clindamycin, azithromycin, and fluconazole. She remained febrile and was transferred after 72 hours to a quaternary children’s hospital. Her past medical history was significant for autoimmune hepatitis diagnosed in 2005, and home medications included 6-mercaptopurine and allopurinol. The patient was born and lives in coastal central California. She traveled 1 month before presentation to Arizona and 1 year prior to visit family in Mexico, both trips were 2 weeks in duration. She had no known sick contacts. Her physical exam upon transfer was notable for a generally well appearance. Her vital signs were as follows: blood pressure 102/67; heart rate 80; respiratory rate 21; SpO2 97% on room air; and temperature 38.1°C. She had decreased breath sounds and dullness to percussion on the right. There was no cervical, axillary, or inguinal lymphadenopathy. Her abdominal exam was benign. The patient was continued empirically on ceftriaxone, clindamycin, azithromycin, and fluconazole. A chest radiograph (Figure 1A) demonstrated a large, free-flowing, right-sided pleural effusion, and a chest computed tomography (Figure 1B) demonstrated the same without parenchymal disease or intrathoracic lymphadenopathy. Her initial laboratory studies demonstrated an elevated c-reactive protein 8.6 (0–0.9 mg/dL) and normal electrolytes, liver function tests, and complete blood count. An infectious laboratory work-up was performed including 2 negative antibody screens for Coccidioides immitis by immunodiffusion, positive tuberculin skin test with 25-mm induration, positive QuantiFERON-Gold IT assay, negative human immunodeficiency virus (HIV) antibody, elevated Mycoplasma pneumoniae serologies immunoglobulin (Ig)M 1:128 and IgG 1:128, and a negative respiratory virus panel. A previous tuberculin skin test in 2006 had 0 mm of induration. On day 5 of illness, a chest tube was placed draining 750 mL of exudative serous fluid with 1240/μL nucleated cells and 92% lymphocytes. The adenosine deaminase was 5.1 U/L (0–9.4). Acid-fast bacilli (AFB), fungal, and bacterial stains were negative as were a mycobacterial and mycoplasma polymerase chain reaction (PCR). Cytology was negative for malignant cells. Her fevers resolved the day after chest tube placement. A pleural biopsy was performed on day 8 of her illness, and fibrinous material was noted in the pleural space intraoperatively. Acid-fast bacilli, fungal, and bacterial stains were negative as was bacterial sequencing, which can identify Mycobacterium tuberculosis complex. Pathology revealed necrotizing granulomatous inflammation but no well formed granulomas. Three induced sputa were AFB smear negative. She remained afebrile and was discharged with presumed latent tuberculosis infection but without a clear diagnosis for her disease after completing a 10-day course of ceftriaxone and 5 days of azithromycin. Fluconazole was also discontinued. On follow-up 1 month after discharge she remained afebrile; however, she had shortness of breath with exertion. Her pleural effusion was unchanged on chest radiograph from the time of discharge. Her M pneumoniae serologies were IgM 1:256 and IgG 1:256 andHistoplasma serologies Case Report