A Case of Lip Pleural Effusion in HIV.

SESSION TITLE: Infectious Disease Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Lymphocytic interstitial pneumonitis (LIP) is an uncommon form of interstitial lung disease in adults that is characterized histopathologically by infiltration of the interstitium and alveolar spaces by lymphocytes. Radiologically LIP is characterized by a diffuse bilateral reticular pattern, and rarely presents as a pleural effusion. A pleural effusion in patients with HIV prompts a wide differential, although LIP is rarely considered apart of this.CASE PRESENTATION: We present a case of a 60 year-old African-American male with long standing HIV and a history of highly active antiretroviral therapy (HAART) non-compliance who presented with a right-sided pleural effusion. Purified protein derivative (PPD) skin test was positive and he was subsequently started on anti-tuberculous treatment. Thoracentesis revealed an exudative effusion with > 80% lymphocytes. Fluid analysis was negative for elevated adenosine deaminase (ADA) level. Acid-fast bacillus (AFB), bacterial, and fungal cultures, as well as cytology, were all negative. Subsequently pleuroscopy was performed, with the pleural biopsy negative for granulomas or tumor cells. A wedge biopsy of the lung was then obtained and pathology was consistent with LIP.DISCUSSION: To the best of our knowledge we believe this to be the first reported case of LIP related pleural effusion in a patient with HIV based on pleural effusion sampling and analysis. The incidence of pleural effusion in HIV is variable and is reported to be 1.7% to 27%1. There are many causes of pleural effusions in patients with HIV, both infectious and non-infectious. Currently, infectious etiologies include bacterial pneumonia, pulmonary tuberculosis, pneumocystis jirovecii pneumonia (PCP), and empyema2. Pleuroscopic pleural biopsy and pleural fluid ADA level have a high sensitivity and specificity for the diagnosis of tuberculosis3.

CONCLUSIONS: Exudative lymphocytic pleural effusion in a PPD positive HIV patient should not be treated with anti-tuberculous drugs if a pleuroscopic pleural biopsy is not diagnostic of tuberculosis and pleural fluid ADA level is normal. Although LIP is an uncommon complication of HIV in adults, it is important to consider it because it usually has a good response to HAART. This unique case emphasizes the importance of broadening the differential diagnosis of pleural effusions in HIV patients especially when available imaging reveals underlying pulmonary reticular opacities.Reference #1: Afessa B.Pleural Effusion and Pneumothorax in Hospitalized Patients with HIV infection: The Pulmonary Complications, ICU Support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study. Chest 2000 Apr;117(4):1031-7.Reference #2: Sahn SA. The Diagnostic Value of Pleural Fluid Analysis. Semin Respir Crit Care Med 1995; 16:269-278Reference #3: Liang QL, Shi HZ,Wang K et al.Diagnostic Accuracy of Adenosine Deaminase in Tuberculous Pleurisy: A Meta-analysis. Respir.Med. 2008; 102: 744-54.DISCLOSURE: The following authors have nothing to disclose: Bashar Mourad, Hammad Bhatti, Adil Shujaat, Abubakr BajwaNo Product/Research Disclosure Information.