The future of medical thoracoscopy in the Kingdom of Saudi Arabia

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Figure 1
- Computerized tomography with contrast. Pleural fluid (white arrow) and thickened pleura (black arrow).
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Figure 2
- Thoracoscopic image of the lung and chest wall. A) Chest wall and B) collapsed lung covered with fibrin. Fibrin attaching the lung to the chest wall (arrow).
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Figure 3
- Thoracoscopic view of the fibrin bands “locules’ being dissected. A) Chest wall, B) fibrin, and C) forceps.

Table 1

- Pleural fluid and serum test findings.

Laboratory test	Results
Pleural PH	7.38
Pleural total protein	50 g/L
Pleural lactate dehydrogenase	431 U/L
Pleural amylase	51 U/L
Pleural cell predominance	Lymphocyte 90%, polymorph 10%
PCR-mycobacterium TB in pleural fluid	Negative
Pleural fluid ziehl-neelsoen stain/acid fast stain	Negative
Lactate dehydrogenase	137
CRP	104 mg/l
WBC	6.5
Sputum AFB	Negative
Procalcitonin	0.06 ng/ml

TB: tuberculosis, CRP: c-reactive protein, WBC: white blood cells, AFB: acid-fast bacilli

Table 2

- Case timeline.

Dates	Relevant past medical history and interventions
09 February 2020	24-year-old male smoker (20 Pk/year).
09 February 2020	Summaries from initial and follow-up visits	Diagnostic testing	Interventions
16 February 2020	Complains of chest pain on right side. Pleural fluid analysis showed lymphocytic pleural effusion.	CT of the chest was carried out which showed large loculated left-sided pleural effusion with thick enhancing pleura. Thoracoscopy was carried out and pleural biopsy was taken which showed necrotizing granuloma. PCR TB tested on 21 February 2020 displayed negative results.	Anti-TB was started on 24 February 2020 in the form of rifampicin, isoniazid, pyrazinamide, and ethambutol.
16 March 2020	Anti-TB medication was started on 24 February 2020.	TB culture carried out on 16 March 2020 tested positive
22 December 2020	Patient had no physical follow-up since March due to COVID 19 pandemic. No complains of chest pain, no cough, fever sputum. Weight gain of 5 kg. looks healthy.	Chest X-ray shows resolution of left-sided pleural effusionx residual pleural thickening and mild volume loss, no new infiltrates bilaterally.	Stopped treatment himself in August 2020 (completed 6 months of Anti TB medication).