title: Use of anabolic-androgenic steroids masking the diagnosis of pleural tuberculosis: a case report.
abstract: BACKGROUND
  Tuberculous pleural effusions are not always easy to diagnose but the presence of a lymphocyte-rich exudate associated with an increased adenosine deaminase level and a positive skin test result are highly sensitive diagnostic signs.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Laboratorio de Tuberculosis, Instituto de Biomedicina, Universidad Central de Venezuela, San Nicolas a Providencia, San José, Caracas, Venezuela. jacobusdeward@gmail.com.
authors.forename: Carlos Fernández
authors.initials: CF
authors.lastname: de Larrea
authors.forename: Aglae
authors.initials: A
authors.lastname: Duplat
authors.forename: Ismar
authors.initials: I
authors.lastname: Rivera-Olivero
authors.forename: Jacobus H
authors.initials: JH
authors.lastname: de Waard