Drug-Resistant (DR) Tubercular Pleural Effusion: A Rare Case

Tuberculosis (TB) is one of the most common infectious diseases in developing countries throughout the world. According to the WHO, there has been a rise in the number of cases of drug-resistant (DR) TB in recent times. Tubercular pleural effusion is challenging to diagnose given the low bacillary load and frequently negative stains for acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) staining. We present a case of successful diagnosis and management of primary extra-pulmonary multidrug-resistant (MDR) tubercular pleural effusion after being misdiagnosed from outside as drug-sensitive extra-pulmonary TB. Initial tests revealed exudative effusion with raised adenosine deaminase (ADA) levels, therefore the patient was started on conventional anti-tubercular therapy with isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E), but the patient did not improve in spite of regular treatment for two months, which warranted further investigations. Therefore Xpert® MTB/R assay (Cepheid Inc., Sunnyvale, USA), line probe assay (LPA), and drug sensitivity testing (DST) of the pleural fluid were sent, which were suggestive of R- and H-resistant tubercular effusion. The patient was started on an oral bedaquiline-containing regimen as per the WHO guidelines and the patient showed considerable improvement on follow up.