Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease

An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Chest-x-ray showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD). Pleural fluid was exudative with predominantly mononuclear cells, negative acid fast bacilli stain, negative cultures, and negative cytology for malignant cells. Due to recurrence of the effusion, 4 weeks after drainage, thoracoscopic pleural biopsy was planned but pleural fluid cultures came back positive for mycobacteria tuberculosis. Patient was started on anti-tubercular therapy but treatment had to be stopped due to liver toxicity. Patient subsequently developed pneumonia and deteriorated despite antibiotic therapy and expired.