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 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.