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 .
Female patient aged 75 years who had no history of chronic disease apart from depression presented at outpatient clinic with complaints of lassitude, loss of appetite, exertional dyspnea for 4 months, and dry coughing for 2 months. Her examination revealed marked decrease in respiratory sounds at basal segments of the right lung. Hematological values, sedimentation, glucose, urea, creatinine, sodium, potassium, total protein, and albumin levels were within normal limits. Levels of alanine aminotransferase (189 U/L), aspartate aminotransferase (113 U/L), cholesterol (251 mg/ dL), and lactate dehydrogenase (LDH) (193 U/L) were also measured. X-ray graphy revealed a dark shadow, consistent with pleural fluid masking the demarcation line between mediastinum and pleura at the inferior zone of the right lung (). Thoracic computed tomography (CT) revealed multiple sites of lymphadenopathy, the largest containing dense calcification 22 mm in size, and marked pleural effusion on the right side (). Milky fluid with high density sampled from pleural effusion did not precipitate after centrifugation, and contained TG (1072 mg/dL), cholesterol (173 mg/dL), LDH (148 U/L), and albumin (2.7 g/ dL) at indicated concentrations. Sudan staining disclosed presence of fat globules. Lymphocyte dominancy was also detected in pleural fluid. Sputum ARB -negativity was detected 3 times, and bronchoscopy of the patient did not reveal any endobronchial pathology. Pleural biopsy was performed. Bronchial lavage and bronchoscopic biopsy results indicated benign condition of chronic pleuritis. Positron emission tomography-CT was obtained to rule out mediastinal tumor. During lymphatic scanning performed to detect etiology of chylothorax, images taken at second, fourth, and sixth hours demonstrated passage of radiographic contrast substance through bilateral inguinal, parailiac, paracaval, and paraaortic lymph nodes, and accumulation of radioactivity in these lymph nodes at popliteal, femoral, and pelvic regions, respectively. On delayed thoracic images, no uptake of radioactivity apart from background activity was observed. Images suggested possible thoracic duct obstruction. Mediastinal lymph node biopsy performed at external center revealed presence of granulomas demonstrating caseous necrosis. Abdominal ultrasound was normal. Antituberculosis treatment was initiated. Symptoms regressed with treatment, and level of liver enzymes decreased. At sixth month, marked regression in pleural effusion was observed ().