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.
An 18-year-old, HIV-negative, male patient was admitted to the hospital complaining of nonquantified weight loss and abdominal pain over a 3 month period. Physical findings included disseminated cutaneous lesions and paraparesis of the lower extremities. Diagnosis of acute paracoccidioidomycosis was confirmed through KOH (potassium hydroxide) direct visualization of typical yeast structures of Paracoccidioides spp. in samples from the skin biopsy (). Abdominal ultrasound revealed extensive peritoneal lymph node involvement, and computerized tomography (CT) with intravenous contrast of the brain revealed a pontomesencephalic lesion (2.3 cm) with ring-enhancement (, white arrow). Chest radiography was normal ().\nLiposomal amphotericin B was administered for 90 days, followed by sulfamethoxazole/trimethoprim. The patient responded well to therapy, but after approximately 1 year of drug therapy, he developed painful abdominal bloating and umbilical protrusion (). Abdominal CT with oral and intravenous contrast revealed a 11.1 by 6.5 cm ovoid lesion in the anterior abdominal wall (, white arrow) that was previously reported as a similar cystic image by ultrasound a month before.\nWhat is your diagnosis?