PLEUREZIA TUBERCULOASĂ - O PROVOCARE DIAGNOSTICĂ (CAZ CLINIC)

Abstract

Introducere. Tuberculoza pleurală reprezintă o formă frecventă de tuberculoză extrapulmonară, deseori dificil de diagnosticat în absenţa unei confirmări bacteriologice. Evaluarea clinică atentă, investigaţii imagistice şi monitorizarea răspunsului terapeutic, poate orienta decizia diagnostică şi terapeutică. Scop. Prezentarea particularităţilor diagnostice şi terapeutice ale unui caz clinic de pleurezie exsudativă, bacteriologic negativ, cu răspuns clinic favorabil la tratament antituberculos. Material şi metode. A fost analizat cazul unui pacient de 45 de ani, cu debut acut, internat pentru sindrom bronşitic, toxico-infecţios, algic. Investigaţiile paraclinice au inclus imagistică toracică, tora-cocenteză, fibrobronhoscopie şi investigaţii de laborator. Bacteriologia lichidului pleural, fără confirmare microbiologică a etiologiei. Rezultate. Imagistica toracică a evidenţiat infiltraţii pneumonice pe stânga cu zone de atelectazii, în faza de resorbţie incompletă şi sindrom pleural lichidi-an cu tendinţă spre închistare. Lichidul pleural (900ml) a fost exsudativ, BAAR, GeneXpert, BACTEC negative. Evoluţia clinică sub tratament antibiotic nespecific a fost fluctuantă. În lipsa unui diagnostic cert, dar în prezenţa unui tablou clinic şi imagistic sugestiv, s-a iniţiat tratament antituber-culos (HPZMfx). După 30 de zile de tratament, s-a observat remisia sindromului inflamator, diminuarea semnificativă a revărsatului pleural şi ameliorarea clinică şi imagistică. Concluzii. Formele paucibacilare de tuberculoză pleurală (formă frecventă de tuberculoză extrapulmonară) rămân o provocare diagnostică. Acest caz evidenţiază rolul major al evaluării clinice, imagistice şi al monitorizării evoluţiei sub tratament în confirmarea indirectă a etiologiei tuberculoase.

Introduction. Pleural tuberculosis is a common form of extrapulmonary tuberculosis, often difficult to diagnose in the absence of bacteriological confirmation. Careful clinical evaluation, imaging investigations, and monitoring of the therapeutic response can guide both diagnostic and treatment decisions. Objective. Presentation of the diagnostic and therapeutic particularities of a clinical case of exudative pleurisy, bacteriologically negative, with a favorable clinical response to antituberculosis treatment. Material and methods. The case of a 45-year-old patient with acute onset, admitted for bronchitis, toxic-infectious, and painful syndrome, was analyzed. Paraclinical investigations included chest imaging, thoracentesis, fiberoptic bronchoscopy, and laboratory tests. Bacteriological analysis of the pleural fluid did not confirm the microbiological etiology. Results. Chest imaging showed left-sided pneumonic infiltrates with areas of atelectasis in the phase of incomplete resolution and a pleural effusion tending toward loculation. The pleural fluid (900 ml) was exudative; AFB smear, GeneXpert, and BACTEC tests were negative. The clinical course under nonspecific antibiotic treatment was fluctuating. In the absence of a definitive diagnosis but with suggestive clinical and imaging findings, antituberculosis treatment (HRZEM-fx) was initiated.After 30 days of treatment, remission of the inflammatory syndrome, significant reduction of the pleural effusion, and clinical and radiological improvement were observed. Conclusion. Paucibacillary forms of pleural tuberculosis (a common form of extrapulmonary tuberculosis) remain a diagnostic challenge. This case highlights the crucial role of clinical and imaging evaluation, as well as monitoring treatment response, in the indirect confirmation of tuberculous etiology.