A 29-year-old man presents with two weeks of fever and left-sided pleuritic pain. Pleural tap: straw-coloured exudate, protein 5 g/dL, lymphocyte-predominant WBC 2,400/uL, glucose 60 mg/dL, adenosine deaminase 48 U/L. Sputum CBNAAT is negative for MTB. What is the most appropriate management?

• A Repeat pleural fluid analysis weekly until the cause declares itself
• B Treat as community-acquired parapneumonic effusion with antibiotics alone
• C Insert an intercostal drain because the protein exceeds 5 g/dL
• D Start antitubercular therapy with corticosteroid cover for the effusion ✓

Explanation

D lymphocytic exudate with ADA above 40 U/L in a young patient in a TB-endemic country is diagnostic of tuberculous pleural effusion for practical purposes, and treatment should start without waiting for culture, which is positive in under a third of cases anyway. Glucose above 60 mg/dL and absence of frank pus argue against complicated parapneumonic effusion, so drainage is unnecessary. Serial observation delays definitive therapy and risks progression.

Reference: Fishman's Pulmonary Diseases and Disorders, 5th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.