A 35-year-old lady not known to have chronic medical illness. Presented to the hospital with chief complaint of left-sided neck swelling and pain of 2 days duration. She did not have a history of fever, cough, weight loss, haemoptysis, chest pain, or shortness of breath. The patient reported no previous history of tuberculosis in the family or any sick contacts, and this was the first time to have such symptoms. The patient is a reformed smoker and drinks socially. There was no past history of trauma or any vigorous exercise.\nUpon arrival to the emergency room, she was afebrile, blood pressure 104/64 mmgh, respiratory rate 18/minute, and pulse rate 83/minute.\nNeck examination revealed left supraclavicular swelling, tender but soft with no palpable lymph nodes, examination of the chest revealed stony dullness, and reduced breath sounds in the basal left zone.\nUltrasonography revealed ill-defined predominantly hyperechoic mixed echogenic area in the left supraclavicular region and left-sided pleural effusion.\nComputed tomography (CT) neck and chest revealed diffuse fat stranding and small lymph nodes noticed in mediastinum giving picture of mediastinitis/inflammatory process involving the left posterior neck muscle and in left pectoralis muscle with diffused smudged fat plane.\nNo collection noted in the neck. Mild left pleural effusion suggestive of chylothorax, Figure , Figure A,B.\nLaboratory investigations including complete blood count, comprehensive metabolic profile and C-reactive protein, lipase, and thyroid function tests were all within normal limits.\nSerum triglyceride 1.9 mmol/L, normal limit 1.7-5.6 mmol/L. Serum cholesterol 4.1 mmol/L, normal limit 5.2-6.2 mmol/L.\nUltrasound-guided diagnostic aspiration of the pleural fluid showed milky alkalotic exudative fluid with predominant lymphocytes, triglycerides level of 2.39 mmol/l, cholesterol level of 3.4 mmol/l, negative gram stain and bacterial culture, negative acid-fast bacilli smear, culture and TB-PCR, and also negative cytology. QuantiFERON was positive.\nThe patient's symptoms started to improve during hospital stay with symptomatic treatment.\nFew days later, the patient underwent repeated CT scan which showed resolution of most of the pleural effusion with normal abdomen CT findings (Figure ).\nFollow-up chest X-ray after 1 month was unremarkable, and the patient was free of symptoms.
A 17-year-old girl was admitted to the Korean University Ansan Hospital with a one-month history of fever, abdominal distention and dyspnea. The patient had been treated in another hospital for 10 days but the cause of ascites and pleural effusion had not been discovered. She was transferred to our hospital for further care. On admission, body temperature was 38.6℃, heart rate was 146/min and body weight was 56 kg. On chest auscultation, breathing sound was decreased on both lower lung fields. Abdominal examination revealed shifting dullness and the lower extremities were severely edematous. A chest radiograph taken on admission showed diffuse fine nodular opacities in both lungs and bilateral pleural effusion. Chest computed tomography (CT) showed pleural effusion of both sides, more serious on the left side, and pericardial effusion and multifocal nodular consolidation on both lung fields (). Abdominal CT showed a large amount of ascites with diffuse peritoneal thickening and multiple necrotic lymphadenopathy in the abdominal cavity, and enhanced wall thickening in the distal ileum and ascending colon (). Initial laboratory results were as follows: white blood cell count 6,670/mm3, hemoglobin 6.7 g/dL, serum total protein 4.6 g/dL and albumin 2.2 g/dL. Thoracentesis and paracentesis were performed to verify the nature of fluid apparent in the chest and abdominal CT images.\nPleural fluid () was turbid and whitish-colored, with pH 8.0, protein level 3.1 g/dL, lactate dehydrogenase of 5,855 IU/L, triglyceride 133 mg/dL and adenosine deaminase 121.6 IU/L. The lactate dehydrogenase ratio of pleural fluid versus serum was 15, consistent with exudate. Ascites () was milk-like and turbid in appearance, pH 8.0, albumin level 0.5 g/dL, triglyceride 864 mg/dL and adenosine deaminase 14.8 IU/L. We diagnosed chylothorax and chylous ascites because the triglyceride level of pleural fluid and ascites were higher than 110 mg/dL and 200 mg/dL, respectively. Direct smear of pleural fluid and ascites for acid fast bacilli (AFB) was positive only in pleural fluid. So, finally we diagnosed the patient as having TB associated with chylothrax and chylous ascites on the basis of positive AFB stain and abdomen CT. Initially, the patient received anti-TB treatment with quadritherapy including isoniazid 300 mg/day, rifampin 600 mg/day, pirazinamide 1,500 mg/day and etambutol 1,200 mg/day. The patient also was put on a high protein and low fat diet with medium chain triglyceride. Mycobacterium tuberculosis was cultured from sputum and pleural fluid on 28th day from admission and the isolate was susceptible to all anti-TB medications. The patient improved continuously after anti-tuberculosis medication, and pleural effusion and ascites were slightly decreased on follow-up chest and abdomen X-ray. The patient was discharged on day 60 of hospitalization with ongoing anti-tuberculosis treatment.