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.
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.