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 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.