A 77-year-old woman presented to our hospital with complaints of persistent cough and low-grade fever for two months. Her medical history revealed glaucoma and osteoporosis seven years previously. Her vital signs were normal except for mild tachypnoea (respiratory rate, 24 breaths/min) and fever at 38.2°C. Physical examination showed decreased breath sounds at the right middle to lower lung fields. Chest X-ray taken at the first visit showed moderate right-sided pleural effusion and right hilar lymphadenopathies (Fig. ) confirmed by enhanced thoracic computed tomography (CT), which revealed a homogeneous enhanced mass as large as 3 cm in diameter (Fig. , arrow) with subcarinal lymphadenopathies (Fig. , arrow head). There was no calcification both in right hilar/mediastinal lymphadenopathies and in lung parenchyma.\nSerum laboratory data were normal except for mild elevation in white blood cell count at 17,000/μL (cell differential of neutrophil 63.3%, eosinophil 1.1%, basophil 0.8%, monocyte 13.3%, and lymphocyte 21.5%) and C-reactive protein at 1.19 mg/dL. Other data were normal; total protein (TP) of 7.1 g/dL, lactate dehydrogenase (LDH) of 217 IU/L, total cholesterol (T-cho) of 202 mg/dL, and triglyceride of 71 mg/dL. An interferon-gamma release assay was positive.\nAlthough thoracentesis of the right side was milky yellow in appearance (Fig. ), no pathogens were isolated including Mycobacterium, and polymerase chain reaction (PCR) for TB or Mycobacterium avium-complex (MAC) was also negative. No malignant cells were identified (class II). Chemical analysis revealed exudative pleural effusion (LDH 126 IU/L and TP 4.2 g/dL) as well as mild elevation of total cell count (1500/μL), predominantly lymphocytes (89%) followed by neutrophils (3%). Interestingly, the level of triglyceride (TG) in pleural fluid was markedly elevated (713 mg/dL), while the values of adenosine deaminase (ADA) (31.7 IU/L) and glucose (107 mg/dL) were normal. She thus met the criteria of chylothorax of TG greater than 110 mg/dL and a pleural to serum T-cho ratio less than 1 (0.48).\nOn the basis of the suspicion of a malignant disease-induced chylothorax, fluorodeoxyglucose–positron emission tomography–CT (FDG–PET–CT) was performed. The FDG–PET–CT demonstrated high FDG uptake in the right hilum, with a maximum standardized uptake value (SUV) of 7.04, and in the subcarinal lymphadenopathies, with a value of 9.65 (Fig. ).\nTwo weeks after the first visit, bronchoscopy was performed. Endobronchial ultrasound-guided transbronchial needle aspiration taken from the subcarinal lymph node showed necrotic tissue with abundant neutrophils or monocytes, which was of no diagnostic value. All retrieved respiratory samples were negative for bacterial or acid-fast culture or PCR methods on TB and MAC.\nOne month later, her symptoms and moderate right-sided pleural effusion persisted; thus, thoracoscopic surgery was performed. Curiously, a noticeable enlarged milky yellow lymphatic duct was found (Fig. , arrow) with its proximal portion seemingly compressed by the adjacent enlarged subcarinal lymphadenopathies (asterisk). Biopsied specimens obtained from the subcarinal lymph node showed epithelioid cell granulomas containing Langhans giant cells (Fig. , arrows) along with necrosis, fibrosis, fibrous venous occlusion, and lymphoid hyperplasia. Although no acid-fast organisms were detected by the Ziehl–Neelsen stain, these findings suggested mycobacterial lymphadenitis associated with TB, she was thus diagnosed with TB lymphadenitis-associated chylothorax. During the thoracoscopic surgery, cauterization of the lymphatic duct was performed, which resulted in a partial resolution of the pleural effusion. The patient rejected treatment for tuberculous lymphadenitis, and four months later (six months after the first visit), the amount of right pleural effusion had rapidly increased again. Thoracentesis found that the colour of the pleural fluid had changed from milky yellow to red (Fig. ) together with an elevation of ADA 77 IU/L and LDH 472 IU/L, suggestive of tuberculous pleuritis. Finally, she was treated with anti-tuberculous drugs, which led to the complete resolution of symptoms, right-sided pleural effusion, and mediastinal lymphadenopathies.
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.