Tuberculosis: The Master Masquerader.

A 54-year-old male presented with a large, left-sided hemorrhagic exudative pleural effusion characterized by lymphocytic predominance and a low adenosine deaminase (ADA) level. A pleural biopsy was performed via medical thoracoscopy. The results of histopathology and GeneXpert-MTB/RIF (Mycobacterium tuberculosis/Rifampicin) (Cepheid, Sunnyvale, California, USA) were inconclusive. PET-CT imaging revealed heightened metabolic activity in the mediastinal lymph nodes, further supported by endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA), showing granulomatous lymphadenitis with caseous necrosis. The patient was diagnosed with tuberculous pleural effusion and showed clinical improvement after initiating anti-tubercular therapy.