Dados do Trabalho

Título

Empyema Necessitans in an HIV-Positive Patient with Miliary and Pleural Tuberculosis

Objetivos(s)

This case report aims to describe the occurrence of empyema necessitans in an HIV-positive patient with miliary and pleural tuberculosis, highlighting the clinical presentation, diagnostic process, and therapeutic approach.

Relato do Caso

A 36-year-old HIV-positive man, with a high viral load of 1,080,000 copies/mm³ and a low CD4 count of 43 cells/mm³, presented with a 3-month history of fever, dry cough, and chest pain. On physical examination, a painful swelling was noted on the anterior chest wall over the 2nd left intercostal space. A contrast-enhanced chest CT scan revealed diffuse miliary nodules, bilateral pleural effusions, mediastinal lymphadenopathies, and a fluid collection extending through the 2nd left intercostal space towards the skin encircling the sternum, consistent with empyema necessitans. Empyema necessitans is a rare complication of empyema characterized by the extension of the fluid collection out of the pleural space into neighboring structures, like the chest wall and surrounding soft tissues. The most common cause is Mycobacterium tuberculosis infection, as in our patient. Less common causes include Actinomyces, Streptococcus, and Staphylococcus infections. Fine-needle aspiration of the swelling on the anterior chest wall yielded pus containing acid-fast bacilli. Real-time polymerase chain reaction (PCR) confirmed the presence of Mycobacterium tuberculosis. The patient was diagnosed with miliary and pleural tuberculosis complicated by empyema necessitans. The patient underwent multiple fine-needle aspirations on the anterior chest wall for pain relief and received antituberculosis therapy, which led to marked clinical improvement.

Conclusão

This case underscores the importance of considering empyema necessitans in patients with advanced HIV and tuberculosis, particularly in the presence of chest wall swelling. Prompt recognition and appropriate management, including drainage and antituberculosis therapy, are critical to achieving favorable outcomes in such complex cases.