Ward Round - Non-resolving pleural effusion in a patient with HIV infection

A 33year-old man was admitted to the medical ward at Queen Elizabeth Central Hospital for evaluation of a pleural effusion that had progressed despite anti-bacterial and tuberculosis treatment. Eight months earlier he was diagnosed with sputum smear alcohol and acid-fast bacilli [AAFB] negative pulmonary tuberculosis. At that time his symptoms were fever, night sweats, cough and shortness of breath. The results of his initial chest X-ray are not known. He received standard tuberculosis treatment (rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months followed by rifampicin and isoniazid for four months). He stated that his symptoms improved during the first two months of tuberculosis treatment,but he then developed a pleural effusion that was tapped three times over the course of the four months prior to admission. Straw colored fluid was obtained twice but results of microbiological and biochemical analysis of the pleural fluid samples were not available.The last time a dry pleural tap was recorded. Courses of amoxicillin and chloramphenicol were given without improvement. Five days before admission he developed progressive complaints of productive cough with brownish sputum and shortness of breath on exertion. He had no constitutional symptoms. He was a lifetime non-smoker and had no exposure to asbestos or significant amounts of particulate matter. He was HIV positive with World Health Organization (WHO)