Therapeutic Drug Monitoring and the Conservative Management of Chronic Tuberculous Empyema: Case Report and Review of the Literature

Below:  Panel a: A posterior-anterior (PA) chest radiograph dated November, 2010 showing a large loculated pleural effusion on the right side. Earlier radiographs (now purged) were reported to show a similar abnormality. Panelb: A PA chest radiograph dated January, 2012 showing an air-fluid level in the previously described loculated effusion. It is consistent with the interval development of a bronchpleural fistula. Panel c: A computed tomographic image dated June, 2012 showing right sided volume loss and a peripherally calcified loculated right hydropneumothorax. Panel d: A PA chest radiograph dated May, 2015 showing the previously described chronic loculated effusion to be reduced in size. An air-fluid level is no longer visible

An 84 year old male immigrant to Canada from Croatia was diagnosed with a CTE after he developed a BPF. The diagnosis was made 62 years after what was, in retrospect, an episode of tuberculous pleurisy. He was treated with computed tomography-guided catheter drainage and TDM-guided high-end dosed anti-TB drugs (serum and pleural fluid drug concentrations) over a 10 month period. Sustained closure of the BPF and mycobacteriologic cure of the CTE was achieved. Drug concentrations in the present case and all other reported cases are summarized and interpreted.

When serum concentrations of the anti-TB drugs isoniazid, pyrazinamide and ethambutol at the high end of the normal range are achieved, pleural fluid concentrations at the low end of the normal range may be anticipated in CTE. Though highly protein bound drugs such as rifampin and moxifloxacin appear to penetrate CTEs less well, their free concentrations in the pleural space may be proportionately higher on account of lower protein concentrations. Interventional radiology and TDM increase the chances that conservative management of CTE will be successful.

Read more at:   http://ht.ly/QOxWf  HT @UAlberta_FoMD