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 33-year-old man, diagnosed case of chronic kidney disease secondary to diabetes mellitus on maintenance dialysis presented to pulmonary medicine outpatient unit with complaints of intermittent fever and weight loss of 2 months duration. On examination, he was febrile (38.4 Celsius) with a respiratory rate of 20/min, pulse rate of 104/min, blood pressure of 140/90 mmHg, and oxygen saturation of 96% on room air. General examination revealed pallor and bilateral pitting pedal edema. His respiratory-, cardiac-, abdominal- and neurological examination was within normal limits. Laboratory examination showed hemoglobin of 7.2 g/dL (normal 11.5–16.5), platelet count of 22 × 109/L (normal 150–500), white cell count of 3.2 × 109/L (normal 4.3–10.8) with neutrophils 65%, lymphocyte 32%, and monocyte of 3%. His glycated hemoglobin was 5.6% (normal <6.5%) and liver function test revealed albumin of 2.2 g/dL (normal 3.5–5 g/dL). Rest of the biochemical investigations were within normal limits. HIV serology was negative. Even though, the patient had normal blood picture and reticulocyte count, bone marrow study was done for his leukopenia.\nChest X-ray posteroanterior (PA) view revealed increased bronchovascular markings [] and computed tomography (CT) thorax with abdomen [] showed bilateral mild pleural effusion with significant mediastinal and abdominal adenopathy. Ultrasound chest was done and it revealed minimal pleural effusion and the same was not tappable. CT-guided fine-needle aspiration was done from paraaortic lymph nodes. Histopathology from bone marrow and cytology of paraaortic lymph nodes showed caseous necrotic granulomatous inflammation suggestive of TB. Acid-fast culture of bone marrow tissue and lymph node aspirate revealed growth of pansensitive mycobacterium TB. He was initiated on modified antitubercular treatment for his kidney disease and the regimen included rifampicin 450 mg daily, isoniazid 300 mg daily, ethambutol 800 mg thrice weekly, and pyrazinamide 1250 mg thrice weekly.\nSix weeks postantitubercular treatment, he came to our casualty with complaints of fever and exertional breathlessness. Patient was febrile (38.6°C) with respiratory rate of 32/min, pulse rate of 120/mine, blood pressure of 150/92 mm of Hg, and oxygen saturation of 92% at room air. Respiratory examination was suggestive of right pleural effusion. Rest of the examination was within normal limits. Chest X-ray PA view showed features suggestive of right moderate to massive pleural effusion []. Diagnostic thoracocentesis revealed milky white fluid and analysis showed total protein 4.1 g/dL, glucose 117 mg/dL, total cholesterol 68 mg/dL, triglycerides 751 mg/dL, and chylomicrons 1050 mg/dL. Cytology of the pleural fluid was negative for malignant cells, cultures for bacteria and mycobacteria were negative. Hence, a diagnosis of chylothorax was made. Repeat CT thorax with abdomen showed an increase in the size of mediastinal and abdominal lymphadenopathy. Hence, the acute worsening in patient clinical condition was attributed to be part of PR/IRIS, developing secondary to antitubercular treatment. His antitubercular therapy was continued and was managed symptomatically with parenteral nutrition, therapeutic thoracocentesis, antipyretics, and oxygen; nonsteroidal anti-inflammatory drugs were deferred in view of renal disease. Despite these he was symptomatic, so initiated on tab prednisolone 1 mg/kg/day. In view of persisting breathing difficulty, increasing oxygen requirement and worsening pleural effusion radiologically after informed consent intercostal drain (ICD) was inserted. Post-ICD X-ray showed partial expansion of lung, so patient was connected to −20 cm water suction. Despite these lung failed to expand, thoracic surgery opinion was obtained and he underwent decortication and interruption of the thoracic duct. Histopathology of the operated specimen showed fibrous connective tissue, fibrinous, and acute inflammatory exudates. Postoperative chest X-ray showed good lung expansion and resolution of right pleural effusion []. Prednisolone 1 mg/kg daily was continued for 2 weeks, then, it was tapered to 0.5 mg/kg and the same was given for 2 more weeks. The patient was discharged on antitubercular treatment and was advised to continue the same for total of 6 months. On follow-up, patient showed good clinical recovery.