CRA43 BEYOND THE NORM: TUBERCULOSIS PRESENTING WITH PLEURAL NODULES DURING PREGNANCY

Nor Syamimi Mohd Isa, Sumithra Appava, Mohd Faizal Abu Seman, Mohd Fauzi bin Jamaluddin, Goon Ai Khiang, Lalitha Pereirasamy
Hospital Pulau Pinang, Pulau Pinang, Malaysia

INTRODUCTION

Pleural involvement in tuberculosis (TB) commonly manifests as unilateral pleural effusion, as seen in 38% of primary TB1. Diagnosis is often challenging in pregnant women due to overlapping symptoms and limited options of diagnostic procedures. We describe a pregnant patient who presented with breathlessness, pleural effusion and pleural nodules which were initially suspected to be malignant.

CASE REPORT

A 27-year-old woman at 20 weeks of gestation, presented with acute dyspnea and a two-day history of fever. Upon examination, she was febrile, dyspneic, and tachycardic, with reduced breath sounds bilaterally. Blood tests only showed elevated C-reactive protein levels with normal WBC. Her infectious disease screening was also negative. Chest x-ray revealed bilateral pleural effusions, with left lower lobe consolidation. Subsequent, thoracic computed tomography showed diffuse pleural thickening, loculated pleural effusions, and multiple pleural nodules. Due to heightened maternal risk, our patient urgently underwent video-assisted thoracoscopic surgery (VATS) by the cardiothoracic team. Intraoperatively, pleural based nodular tumours were observed, which were biopsied. Histopathological examination revealed caseating granulomas with a positive Ziehl-Nielsen stain, pathognomonic of tuberculosis. Anti-tubercular therapy was quickly commenced with good effect and resolution of symptoms.

DISCUSSION

One-third of women with TB fall within the reproductive age. TB symptoms are often masked by physiological changes in pregnancy, leading to delayed diagnosis and catastrophic consequences. In our patient, the presence of pleural nodules raised suspicions of various differential diagnoses, including malignant mesothelioma, pleural lymphoma, and even pleural metastasis. However, in an endemic country, TB remains a significant consideration. Reports of tuberculosis presenting with pleural based tumours/nodules are rare in literature and cases in pregnant women have not been reported.