Case Vignette

A 62-year-old female with a background of Hashimoto’s thyroiditis presented with 14 days of pleuritic chest pain followed by acute-onset non-productive cough and progressive exertional dyspnea. Examination revealed reduced air entry and decreased vocal fremitus over the left infra-axillary and infra-scapular regions. Inflammatory markers were markedly elevated (CRP 186 mg/L), with no documented fever.

Chest radiograph showed bilateral pleural effusion (L > R). Pleural fluid analysis revealed an exudative effusion (protein 4.1 g/dL) with mononuclear predominance (80%), low ADA, and sterile microbiology (negative Gram stain, KOH, AFB, CBNAAT, and cultures). Cardiac evaluation (2D-ECHO, CT-CAG, cardiac biomarkers) was unremarkable. HRCT thorax demonstrated fatty proliferation with pericardial thickening, suggestive of a chronic inflammatory process.

The patient showed clinical and radiological improvement with NSAIDs alone, along with a declining CRP trend.

Q. What is the most likely driver of this patient’s bilateral exudative pleural effusion with pericardial thickening?

A. Tuberculous pleurisy

B. Congestive heart failure

C. Acute bacterial mediastinitis

D. Post-viral inflammatory mediastinitis with reactive pleuro-pericarditis