80Y,M,cough ,chest pain since 15days,no fever,anorexia etc. consulted ortho on 3rd oct,cxr done,refer to me,diagnostic tapping done on 12th oct,Put in ICD today,routine lab, RV, was normal except wbc 11500,N80%.ESR 45mm.cxrays and pl fluid reports attached. plz guide whether to start AKT,if yes on what ground?if no,suggest further plan.

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Add one more step of cbnaat for this straw colored pleural fluid then start akt as per result ,but sir here are some issues must be rectified before all, pleural fluid analysis - don't we use light's criteria to make it a differential report between transudate and exudate , pleural fluid ada level is also a big dilemma some literature says more than 100 u confirms without doubt about presence of tb and 36 is taken cutoff for the same, lymphocytosis is indicative of tb but presence of blood (if not of trauma of drainage) creates doubt of malignancy ,so we definitely needs some more workup before reaching to final diagnosis

Sir cbnaat is not senstive when pleural fluid is sample....biopsy is more sensitive for cbnaat ..so pleural fluid for tb pcr can be sent
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Increased protein Decreased Sugar TLC -1500 Lymphocytes -100 % ADA - 55.9 All these reports are im favour of chronic infective etiology... Cultyre and CBNAAT of pleural fluid can be sent before starting ATT

ATT should not be started on basis of these plural fluid reports. ADA is in strong suspect range. It is lymphocytes rich exudate. Sug.clinical correlation Imaging Tb igra..whole blood Cb naat...plural fluid..for etiologic diagnosis

Left sided hydropneumothorax cause tubercular. As per the pleural fluid reports it’s suggest tubercular etiology. Start ATT of the patient sir.

Also send fluid for cbnaat
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Start akt On Ada cell positive with lymphocytes but additional gene expert & fluid for culture sensitivity

ATT should not be started on the basis of these plural fluid reports. Needs further investigations and evaluation to conclude and treatment.

Thanks Dr Ramesh.
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If you are having doubt with pleural fluid ADA you can go with pleural fluid CBNAAT which have low sensitivity ,but you can also try to do pleural fluid interferom gamma levels,you can do ration of ADA1:ADA2

Lymphocytic rich high protein exudative left sided effusion most likely infective particularly Tb ...considering old age and Indian origin we can go for ATT...and better to conform with CBNAAT too sir...

Yes, certainly because wvc high &n80. Since esr 45mmsuggestive of chronic infection ,to rule out other etiology.like pneumonitis cystitis carini .or is tapping result malignancy or tb

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