|Year : 2014 | Volume
| Issue : 1 | Page : 9-11
A rare cause of pleurisy in pregnancy: Tuberculosis
Aysegul Baysak1, Gulfem Ece2, Julide Celdir Emre3, Adnan Tolga Oz1, Erkan Sahin4
1 Department of Chest Diseases, Izmir University School of Medicine, Izmir, Turkey
2 Department of Medical Microbiology, Izmir University School of Medicine, Izmir, Turkey
3 Department of Chest Diseases, Turgutlu State Hospital, Manisa, Turkey
4 Department of Radiology, Izmir University School of Medicine, Izmir, Turkey
|Date of Web Publication||17-Feb-2014|
Department of Chest Diseases, Izmir University School of Medicine, Yeni Girne Blv. 1825 sokak No: 12 Karsiyaka, Izmir
Source of Support: None, Conflict of Interest: None
Tuberculosis is a granulomatous infectious disease of lungs due to Mycobacterium tuberculosis. Tuberculosis is a chronic disease and tuberculosis pleurisy takes place with acute disease symptoms. We aimed to present a rare case of young pregnant woman with pleural effusion due to tuberculosis in light of literature.
Pleurisy, pregnancy, tuberculosis
|How to cite this article:|
Baysak A, Ece G, Emre JC, Oz AT, Sahin E. A rare cause of pleurisy in pregnancy: Tuberculosis. Sifa Med J 2014;1:9-11
| Introduction|| |
Tuberculosis, pneumonia, collagen vascular diseases, and pulmonary emboli are major sources of exuda type pleural effusion in young women. Tuberculosis pleurisy is more common in children and adolescents. It is also detected more in countries with a higher incidence of human immunodeficiency virus (HIV) infection.  Morbidity due to tuberculosis infection is usually higher in male gender; but the mortality rate is highest in the age range of 15-49 years (80%). This is especially a risk for women of childbearing age.  In our case report we aimed to present a rare case of young pregnant woman with pleural effusion due to tuberculosis in light of literature.
| Case Report|| |
A 28-year-old woman with 27 week pregnancy was admitted to University Chest Diseases outpatient clinic. The patient had right flank pain particularly increased with motion. The patient history did not have fever or dyspnea. She did not have a previous history of pulmonary disease or an underlying disorder. She smoked for 14 years and quitted during pregnancy. Her physical examination revealed no pulmonary sound on the basal zone of the right hemithorax. The pulmonary sound was normal on the other parts. Thorax ultrasonography indicated plevral effusion on the right hemithorax. Chest X-ray was applied by protecting the abdominal part of the patient [Figure 1]. The X-ray showed pleural effusion on the right hemithorax at the level of fourth costa. The patient underwent thorasynthesis. Approximately 1,000 cc exuda type fluid was aspirated. The sample was sent to microbiology and pathology laboratories. Antibiotic treatment was initiated and meanwhile adenosine deaminase (ADA) level of the pleural fluid was measured as 149 U/L. Kinyoun stain was negative. The complaints of the patient still continued. The patient was iniated isoniazid, rifampicin, pyrazinmaide, and ethambuthol treatment, and accepted the case as pleurisy due to tuberculosis. The tuberculosis culture of the pleural fluid reported Mycobacterium tuberculosis on the 1 st month of the incubation. No drug resistance was reported. Chest X-ray in the 8 th month showed obvious regression of the pleural effusion [Figure 2].
| Discussion|| |
Tuberculosis is a chronic disease; but tuberculosis pleurisy comes up with symptoms of acute disease.  The most common symptoms are cough without sputum, pleurotic flank pain, and dyspnea due to increased fluid. Reflux and allergy may be the major causes of cough in pregnancy. Flank pain and dyspnea can be observed as nonspecific symptoms. In our case there was only flank pain increased with motion.
Effusions due to tuberculosis are usually on one side and effusions are mostly single-sided and the amount of fluid varies from low to middle.  If the symptoms exist and the amount of fluid is mild to massive; symptomatic punction can be recommended.
Thorasynthesis and pleural biopsy are recommended for diagnosis. Pleural fluid is always an exuda type. Neutrophil increase may be detected during the first few days; but then lymphocyte predominancy is obvious. , Detection of mesothelial cells is rare except in cases infected with HIV. The glucose level may be low; but it is not under 60 mg/dl.  The increased level of ADA is meaningful for diagnosis of tuberculosis; but it can also show an increment in empyema, lymphoma, and malignities other than lymphoma. ADA increase is an important tool for diagnosis in countries where the tuberculosis and tuberculosis pleurisy prevalance is high; but in regions with low prevalance specificity of the assay decreases.
The positivity of Kinyoun stain in pleural fluid varies between 3 and 15%. Culture of pleural fluid takes a long amount of time and reports small amount of positive results. Automatized systems for tuberculosis culture report results more rapidly and efficiently.  On the other hand, pleural biopsy culture report showed 60% positive results for tuberculosis compared to direct microscopic examination and culture of pleural fluid. Although the diagnosis is difficult in tuberculosis pleurisy; the response to tuberculosis treatment is high. These cases may also recover without treatment; but 65% of these patients can lead to pulmonary or extrapulmonary tuberculosis infections without treatment. 
Tuberculosis pleurisy may take place simultaneously with pulmonary tuberculosis. Because of this data all patients with tuberculosis pleurisy should be carefully evaluated for pulmonary parenchymal signs and examined by Kinyoun stain. Pulmonary parenchymal symptoms may accompany 20-50% of the patients with tuberculosis pleurisy. , Parenchymal signs were not detected in our case report.
Pregnancy does not have any effect on progenosis of tuberculosis infection.  Diagnosis may delay due to nonspecific signs similar to pregnancy and avoidance of radiological diagnostic techniques. , Late diagnosis and insufficient therapy can cause increase the risk of abortus and low birth weight and Apgar score. 
The pregnant woman may avoid using treatment due to nausea and vomiting. This can decrease the compliance of the patient to the treatment. The clinician should emphasize on the importance of treatment for both the baby and the mother. Direct observational treatment can be applied to increase compliance to the treatment. Immediate initiation of treatment in pregnancy is important. , First line antituberculosis drugs except streptomycin are applied successfully.
Tuberculosis pleurisy in pregnancy is a rare and difficult clinical picture because of complicated diagnosis due to nonspecific symptoms. Tuberculosis should be kept in mind in pregnant women with pleural effusion.
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[Figure 1], [Figure 2]