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Case Report Open Access

Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report

  • Authors:
    • Hiroki Ito
    • Kentaro Yano
    • Yuya Suzuki
    • Yoshitaka Taniguchi
    • Fumiya Sato
    • Shigemitsu Sato
    • Takuo Hirose
    • Ikuko Oba-yabana
    • Takefumi Mori
  • View Affiliations / Copyright

    Affiliations: Division of Nephrology and Hypertension, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi 983‑8536, Japan, Division of Integrative Renal Replacement Therapy, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi 983‑8536, Japan
    Copyright: © Ito et al. This is an open access article distributed under the terms of Creative Commons Attribution License [CC BY 4.0].
  • Article Number: 228
    |
    Published online on: September 19, 2025
       https://doi.org/10.3892/etm.2025.12978
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Abstract

Accelerated malignant hypertension frequently manifests as multiple organ dysfunctions. However, persistent symptoms despite appropriate antihypertensive therapy warrant investigation of concurrent pathologies, particularly in patients with risk factors for opportunistic infections. A 57‑year‑old woman with untreated hypertension presented in August 2024, with markedly elevated blood pressure (208/122 mmHg), systolic dysfunction (ejection fraction, 42.5%) and acute kidney injury (creatinine 4.74 mg/dl). Accelerated malignant hypertension with multiple organ damage was diagnosed based on these findings. Despite optimal antihypertensive and diuretic therapy, pleural effusion and renal function progressively worsened. Thoracentesis revealed a lymphocyte‑predominant exudative effusion with elevated adenosine deaminase levels. Subsequent investigations confirmed tuberculous pleuritis and peritonitis, ultimately diagnosed as miliary tuberculosis. Excessive diuretic therapy for presumed heart failure‑related effusion exacerbates renal injury. Following initiation of antituberculous therapy, pleural effusion and renal function markedly improved. This case emphasizes the importance of reevaluating initial diagnoses when the clinical responses are suboptimal. In patients with multiple risk factors, particularly diabetes mellitus and kidney dysfunction, concurrent tuberculosis should be considered for treatment‑refractory symptoms.
View Figures

Figure 1

Radiological and imaging findings on
admission. (A) Chest radiograph showing cardiomegaly with bilateral
pleural effusion, predominantly on the right side. (B) Chest
computed tomography image showing bilateral pleural effusion
without significant parenchymal abnormalities. (C) Abdominal
computed tomography showing subtle bilateral renal atrophic
changes. (D) Transthoracic echocardiography revealing diffuse left
ventricular hypokinesis with a reduced ejection fraction of 42.5%.
(E) Fundoscopic examination confirming hypertensive retinopathy
with hemorrhage and exudates.

Figure 2

Neurological imaging findings. (A)
Diffusion-weighted magnetic resonance imaging revealing multiple
acute infarctions involving the pons, bilateral basal ganglia, left
thalamus and left parieto-occipital region (arrow). (B) Magnetic
resonance angiography showing vessel irregularities without obvious
occlusion (arrow).

Figure 3

Radiological findings on hospital day
20, prior to the diagnosis of tuberculosis. (A) Chest radiograph
showing persistent bilateral pleural effusions with notable
progression of left-sided effusion. (B) Computed tomography
revealing persistent bilateral pleural effusions despite optimal
antihypertensive and diuretic therapy.

Figure 4

Thoracoscopic, intraoperative and
histopathological findings confirming disseminated tuberculosis.
(A) Photomicrograph of the pleural biopsy specimen showing a
caseating granuloma surrounded by epithelioid cells and lymphocytes
(H&E stain; magnification, x100). (B) Photomicrograph of a
peritoneal nodule biopsy showing a caseating granuloma, confirming
tuberculous peritonitis (H&E stain; magnification, x100). (C)
Thoracoscopic view of the right pleural cavity, showing thickened
pleura and multiple nodules (arrows indicate the nodules). (D)
Intraoperative view during peritoneal dialysis catheter placement
revealing multiple white nodules disseminated across the peritoneum
(arrowheads indicate the nodules).

Figure 5

Follow-up radiological findings in May
and June 2025, demonstrating sustained treatment response. (A)
Chest radiograph showing sustained resolution of pleural effusion.
(B) Chest computed tomography confirming the complete resolution of
effusion and no new parenchymal abnormalities.
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Copy and paste a formatted citation
Spandidos Publications style
Ito H, Yano K, Suzuki Y, Taniguchi Y, Sato F, Sato S, Hirose T, Oba-yabana I and Mori T: Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report. Exp Ther Med 30: 228, 2025.
APA
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S. ... Mori, T. (2025). Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report. Experimental and Therapeutic Medicine, 30, 228. https://doi.org/10.3892/etm.2025.12978
MLA
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S., Hirose, T., Oba-yabana, I., Mori, T."Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report". Experimental and Therapeutic Medicine 30.6 (2025): 228.
Chicago
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S., Hirose, T., Oba-yabana, I., Mori, T."Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report". Experimental and Therapeutic Medicine 30, no. 6 (2025): 228. https://doi.org/10.3892/etm.2025.12978
Copy and paste a formatted citation
x
Spandidos Publications style
Ito H, Yano K, Suzuki Y, Taniguchi Y, Sato F, Sato S, Hirose T, Oba-yabana I and Mori T: Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report. Exp Ther Med 30: 228, 2025.
APA
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S. ... Mori, T. (2025). Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report. Experimental and Therapeutic Medicine, 30, 228. https://doi.org/10.3892/etm.2025.12978
MLA
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S., Hirose, T., Oba-yabana, I., Mori, T."Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report". Experimental and Therapeutic Medicine 30.6 (2025): 228.
Chicago
Ito, H., Yano, K., Suzuki, Y., Taniguchi, Y., Sato, F., Sato, S., Hirose, T., Oba-yabana, I., Mori, T."Refractory pleural effusion in malignant hypertension leading to an unexpected diagnosis of tuberculosis: A case report". Experimental and Therapeutic Medicine 30, no. 6 (2025): 228. https://doi.org/10.3892/etm.2025.12978
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