Persistent pleural tuberculosis presenting as chest wall swellings in an immunocompetent patient: A rare case report in a low resource setting

Introduction

Although it is primarily a pulmonary disease, extra-pulmonary TB has been reported in 15 % of TB patients and it can affect any body system including the pleura. Pleural tuberculosis can result into empyema thoracis which can further complicate if left untreated to empyema necessitans. This requires high index of suspicious for prompt medical and surgical management.

Case presentation

A 41-year-old immunocompetent male presented with a two-month history of chest wall swellings. The swellings were associated with intermittent fevers and night sweats. Clinical examination revealed anterior and posterior left chest swellings, tender, and fluctuant. Chest X-ray showed left hemithorax opacification with right sided mediastinal shift. A chest tube was inserted and pus was drained and it was positive for Mycobacterium Tuberculosis. He was continued with anti-tuberculous therapy for 7 more months with good outcome.

Discussion

Empyema necessitans is a rare complication of tuberculous thoracis in which the pus invades the chest wall resulting into pus collection under the skin. Areas of the chest wall likely to be affected are those with relative lung adherence to the chest wall which are anterior superior and posterior inferior chest wall. The inflammatory process can result into classic signs of inflammation including swelling, warmth, erythema, pain, but in other patients it just presents as a swelling under the skin. Management involves pus drainage through chest tube and anti-tuberculous therapy.

Conclusion

Healthcare providers must keep high index of suspicion for empyema necessitans in patients presenting with chest wall masses especially when they have history of tuberculosis.