Use of anabolic-androgenic steroids masking the diagnosis of pleural tuberculosis: a case report

We report a case of pleural tuberculosis in a 31-year-old white male patient from Caracas, Venezuela who was negative for human immunodeficiency virus and presented 2 weeks after injecting the anabolic-androgenic steroid nandrolone decanoate, in whom all the tests for tuberculosis were initially negative; an eosinophilic pleural effusion with a low adenosine deaminase level, a negative tuberculin skin test and negative for acid-fast bacilli staining and culture of the pleural fluid. After excluding other causes of eosinophilic pleural effusion malignant pleural effusion was suspected. The patient did not return until 4 months later. The second thoracentesis obtained a pleural fluid suggestive for tuberculosis, with a predominance of lymphocytes, an elevated adenosine deaminase level (51 U/l) and a positive tuberculin skin test. Culture of pleural fragments confirmed pleural tuberculosis.This case suggests that the use of an anabolic-androgenic steroid masks the definitive diagnosis of pleural tuberculosis by changing the key diagnostic parameters of the pleural fluid, a finding not previously reported. Available evidence of the effects of anabolic steroids on the immune system also suggests that patients using anabolic-androgenic steroids might be susceptible to developing tuberculosis in either reactivating a latent infection or facilitating development of the disease after a recent infection.The cause of an exudative pleural effusion (EPF) is often difficult to determine, but tuberculosis (TB) must be considered, especially in countries with a high prevalence of TB. The diagnosis of a tuberculous pleural effusion is based on the Ziehl-Neelsen staining for acid-fast bacilli (AFB) and on the growth of Mycobacterium tuberculosis from pleural fluid or biopsy. However, if no AFB are found, cultures take 4–6 weeks to be positive, and therapeutic decisions need to be made before the results are available. A positive tuberculin skin test (TST) can be helpful, but may be n