# Tuberculosis: The Master Masquerader

## TL;DR

A 54-year-old man with a pleural effusion was diagnosed with tuberculosis after inconclusive tests and showed improvement with treatment.

## Contribution

Highlights the diagnostic challenges of tuberculous pleural effusion and the role of advanced imaging and procedures in confirming the diagnosis.

## Key findings

- Histopathology and GeneXpert-MTB/RIF results were inconclusive for tuberculosis.
- PET-CT and EBUS-TBNA confirmed granulomatous lymphadenitis with caseous necrosis, leading to a tuberculosis diagnosis.
- The patient improved clinically after starting anti-tubercular therapy.

## Abstract

A 54-year-old male presented with a large, left-sided hemorrhagic exudative pleural effusion characterized by lymphocytic predominance and a low adenosine deaminase (ADA) level. A pleural biopsy was performed via medical thoracoscopy. The results of histopathology and GeneXpert-MTB/RIF (Mycobacterium tuberculosis/Rifampicin) (Cepheid, Sunnyvale, California, USA) were inconclusive. PET-CT imaging revealed heightened metabolic activity in the mediastinal lymph nodes, further supported by endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA), showing granulomatous lymphadenitis with caseous necrosis. The patient was diagnosed with tuberculous pleural effusion and showed clinical improvement after initiating anti-tubercular therapy.