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Case of the Month - August 2015

Dr Jeremy Nel, Dept of Infectious Diseases, Helen Joseph Hospital

A 28-year-old man presented at a local district hospital complaining of a chronic cough (> 1 month duration) with associated right-sided pleuritic chest pain, anorexia and weight loss. A chest X-ray showed a right-sided pleural effusion. An intercostal drain was inserted, and the pleural fluid taken before antibiotics were commenced, showed:

Test Result
Glucose1.3 mmol/L
Protein36 g/L
Polymorphs750 000 /μL
Erythrocytes10 000 /μL
Gram stainNo bacteria observed
Bacterial cultureNo growth after 2 days
Auramine stainNegative
GeneXpert MTB/RifNegative

Pleural fluid cytology revealed no malignant or mesothelial cells. A second chest X-ray, taken after the intercostal drain insertion, additionally showed a right pneumothorax, revealed after drainage of several litres of purulent fluid.

His blood tests on admission were as follows:

White cell count (× 109/L) 29.69 HIV (ELISA) Negative
Haemoglobin (g/dL) 10.4 CRP (mg/L) 289
MCV (fL) 86.5 Total bilirubin (μmol/L) 13
Platelets (× 109/L) 652 Conj. bilirubin (μmol/L) 9
Sodium (mmol/L) 127 Protein (g/L) 87
Potassium (mmol/L) 5.0 Albumin (g/L) 11
Chloride (mmol/L) 93 ALP (U/L) 501
Bicarbonate (mmol/L) 21 GGT (U/L) 138
Urea (mmol/L) 7.4 ALT (U/L) 14
Creatinine (μmol/L) 73 AST (U/L) 37

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