An HIV-exposed uninfected 20-month-old boy presented to Chris\nHani Baragwanath Academic Hospital in Johannesburg, South Africa,\nwith a 2-day history of shortness of breath, cough and noisy breathing.\nHe had also experienced night sweats, fever and vomiting for a week.\nTwo weeks prior to this presentation, he had been diagnosed with\nbacteriologically unconfirmed PTB at a primary healthcare clinic and\nwas empirically started on a four-drug antituberculosis treatment\nregimen (rifampicin, isoniazid, pyrazinamide and ethambutol). The\ndiagnosis was based on a chest X-ray and a positive Mantoux\ntest. His father (a household contact) had been diagnosed with PTB,\nand had been on first-line antituberculosis treatment for 4 months. \nThe boy had had normal growth and development up to 1 year of age,\nbut had subsequently lost weight, and fallen from a weight-for-height\nz-score +2 to the median over the preceding 8 months.\nOn admission, he was apyrexial, tachycardic and in moderate\nrespiratory distress, with oxygen saturations of 97% in room air. He\nhad marked chest wall indrawing and bilateral posterior cervical\nand axillary lymph nodes (<0.5 cm in diameter). He was clinically\nhyperinflated, with bilateral wheezing. The rest of his clinical\nexamination was normal.\nHe was diagnosed with viral bronchiolitis, and therefore a chest\nX-ray was not performed. He was started on oxygen and hypertonic\nsaline nebulisation. He responded poorly to this initial treatment\nand was therefore started on oral corticosteroids and amoxicillin on\nday 2 of hospitalisation, and his first-line antituberculosis treatment\nwas continued. Gastric aspirate samples for microscopy for acid-fast\nbacilli, Xpert MTB/RIF (Cepheid, USA) and culture for mycobacteria\nwere negative.\nDuring his hospital admission period his wheezing persisted,\nand he remained in moderate respiratory distress. On the fifth day\nof admission, he developed percussion dullness and absent breath\nsounds over the right hemithorax.\nA chest X-ray at this point revealed a large right-sided pleural\neffusion . A computed tomography scan of the chest revealed\nhilar lymphadenopathy and a large right-sided pleural effusion. The\nthoracic duct could not be visualised. Diagnostic pleurocentesis\nconfirmed a chylothorax. It was suspected that tuberculous lymph\nnodes had eroded the thoracic duct causing the chylothorax, and\ntherefore a bronchoscopy was performed, which revealed caseating\nlymph nodes in the right main bronchus suggestive of TB, and 90%\nobstruction of the left main bronchus. The Xpert MTB/RIF (Cephaid,\nUSA) test on a bronchoalveolar lavage specimen identified rifampicinresistant Mycobacterium tuberculosis. Gastric aspirates, pleural fluid\nand bronchoalveolar lavage samples were all smear-negative for acidfast bacilli and mycobacterial culture-negative.\nThe chylothorax was managed with a low-fat diet (with additional\nmedium-chain triglycerides), therapeutic taps for worsening\nrespiratory distress and an octreotide infusion. The boy was\ncommenced on multidrug-resistant TB (MDR-TB) treatment\n(amikacin, levofloxicin, ethionamide, terizidone, pyrazinamide,\nethambutol and high-dose isoniazid) and oral steroids.\nFor further management, he was transferred to a hospital dedicated\nto the care of MDR-TB patients. One month later, he showed marked\nclinical improvement, with almost complete radiological resolution of\nthe chylothorax, and reduced hilar lymphadenopathy . The\nfull case overview is shown in .
A 42-year-old male presented with pain in the epigastrium, radiating to the back and feeling of fullness of the abdomen for a duration of six months. He gave history of loss of appetite and weight loss of 5 kg over a period of six months. He complained of progressive breathlessness on exertion for a period of one month. He gave no history of cough, expectoration, fever, wheeze or hemoptysis. He did not give any history of trauma.\nHe was working as a casual laborer in the agriculture sector. He consumed alcohol on at least five days in a week and smoked at least two packets of beedis in a week.\nNine months back he was admitted to a hospital for treatment of acute abdominal pain. A diagnosis of acute on chronic calcified pancreatitis was made. The most probable cause for the chronic pancreatitis was due to excessive alcohol intake by the patient. A pancreatoduodenostomy was performed on him. He remained asymptomatic for a period of three months. A follow-up ultrasound done after three months showed multiple calcification of the head of the pancreas with bulky tail, and minimal ascites and one old calcified granuloma in the right lobe of the liver. He was put on a low-fat diet, small frequent feeds and received pancreatic enzyme supplements from the time he was operated upon.\nOn examination he was thin built and emaciated and was systemically well. There were no palpable lymphadenopathies. He had bilateral pitting pedal edema. On chest examination there was diminished movement of the right lower hemithorax when compared to the left. Percussion of the right hemithorax yielded a dull note in the right infraaxillary and infrascapular areas which persisted on deep inspiration. On auscultation diminished breath sounds in the right basal regions were apparent. On palpation his abdomen was distended, epigastric tenderness was present and bowel sounds were heard. Examinations of other systems were unremarkable.\nHis hemogram revealed low hemoglobin of 9.2 mg/dl and elevated erythrocyte sedimentation rate of 32 mm in half hour. Renal and liver function tests were within normal limits. Sputum smear examination for acid-fast bacilli was negative in the two samples obtained. The result of the Mantoux test done with 5 TU and read after 48 h was 0 mm. Peripheral smear examination for microfilaria was negative. Chest skiagram revealed apparent elevation of right hemidiaphragm with lateral peaking, a heterogeneous opacity in the right lower zone and loss of lung volume on the right hemithorax. A lateral decubitus view revealed tracking of fluid.\nUltrasonogram of chest was done and pleurocentesis was performed at the site marked for pleural fluid aspiration. The pleural fluid aspirated was milky white in color and odorless [ and ].\nWith pleural fluid triglyceride >110 mg/dl and pleural fluid to serum cholesterol ratio less than 1 a diagnosis of chylothorax was made.[] Pleural fluid cytology was negative for malignant cells. Ziehl-Neelsen staining of pleural fluid smear was 3 plus positive for AFBs []. Computed tomography (CT) scan of the chest showed right-sided hydrothorax with partial collapse of the right lower lobe and fluid in minor fissure []. CT scan of abdomen was suggestive of acute on chronic pancreatitis with ascitis. Ascitic fluid was so minimal that ascitic fluid aspiration could not be done. It did not reveal any evidence of mass lesion or enlarged lymph nodes.\nThe patient was started on antituberculous treatment with a four-drug regimen with isoniazid, pyrazinamide, rifampicin and ethambutol. He did not give consent for intercostal drainage or any surgical or interventional procedure, hence pleural aspiration was done in a staggered manner in three sittings with 500 ml being aspirated in each sitting. As octreotide was not available in our institution he was put on a low-fat diet, intravenous fluids and monitored. The patient's general condition improved and he was discharged from the hospital after three weeks.