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 15-year-old female was admitted to our department with the complaints of breathlessness, and off and on fever for 1 month. She came from a nonendemic zone of filariasis in Uttar Pradesh. The resting pulse rate was 92/min and blood pressure was 112/74 mmHg. There was no history of contact with a tuberculosis patient. Her physical examination revealed hard, mobile lymph nodes of size 2 × 2 cm approximately, present bilaterally in the cervical region, and pallor. On chest examination, there was stony dull note localized to the bilateral infrascapular, lower axilla. Rest of the systems were within normal limits.\nHer blood examination revealed anemia, and hypoalbuminemia but normal total and differential leukocyte counts. Her chest x-ray revealed bilateral pleural effusion []. The pleural fluid was aspirated (about 2.0 l from left and 1.2 l from right) on both sides that revealed a milky white fluid. Then we thought about the chylothorax. Clearing of the pleural fluid by adding ethyl-ether into it leads to the exclusion of pseudochylothorax. The pleural fluid of both sides was sent for examination that revealed, for the right side, protein 4.2 g%, sugar 44 mg%, and total leukocyte count 3400 cells/mm3; differential leukocyte count was neutrophils 20, lymphocytes 80, pleural fluid triglyceride 535 mg%, and pleural fluid cholesterol 24.8 mg%; pleural fluid of the left side revealed protein 4.0 g%, sugar 40 mg%, and total leukocyte count 3280 cells/mm3; differential leukocyte count was neutrophils 34, lymphocytes 66, pleural fluid triglyceride 188.0 mg%, and pleural fluid cholesterol 24.0 mg% []. Serum triglyceride and serum cholesterol was 72.7 mg% and 71.9 mg%, respectively. The Ziehl-Neelsen stain of the pleural fluid was negative but Mycobacterium tuberculosis was isolated on the Lowenstein–Jensen culture. The pleural fluid culture for pyogenic organisms was sterile in nature on both sides. PPD showed no indurations. Her biopsy of the cervical lymph node revealed caseating granuloma, and the Bactec culture for M. tuberculosis was also positive in the cervical lymph node biopsy specimen. Her abdomen ultrasound also revealed multiple retroperitoneal and para-aortic lymphadenopathy. Thus a diagnosis of bilateral chylothorax secondary to tuberculosis with cervical lymphadenopathy was established.\nTo confirm the exact site of the thoracic duct tear, lymphangiography was planned but her parents refused for further investigations.\nShe was put on standard 6-month antitubercular treatment: a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol was started for 2 months followed by isoniazid and rifampicin for a further 4 months. Following this, she showed clinical as well as radiological improvement and chylothorax resolved after 2 months of treatment [], and on regular follow-up she had no further symptoms.