A 38-year-old woman develops pleural effusion 6 weeks after starting treatment for pulmonary TB. Sputum smears are now negative. She is haemodynamically stable and the effusion is left-sided, moderate in size. Pleural fluid shows: exudate, ADA 78 U/L, lymphocyte predominance. What is the best next step?
- A Continue anti-TB therapy; add corticosteroids to reduce pleural inflammation ✓
- B Stop all anti-TB drugs and investigate for drug-induced pleuritis
- C Perform emergent thoracocentesis and pleurodesis
- D Change the anti-TB regimen to second-line drugs
Explanation
A pleural effusion developing during treatment of pulmonary TB can represent a paradoxical reaction — immune reconstitution of a pre-existing tuberculous pleuritis. ADA > 40 U/L with lymphocyte predominance supports TB pleuritis. The effusion is not an indication to stop anti-TB therapy; continuation is correct. Addition of corticosteroids (prednisolone 1 mg/kg tapering over 6–8 weeks) accelerates resolution and reduces fibrous thickening. Emergent thoracocentesis is reserved for large, symptomatic effusions causing respiratory compromise. Drug-induced pleuritis is uncommon with standard ATT.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.