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 42-year-old male presented with pain in the epigastrium, radiating to the back and feeling of fullness of the abdomen for a duration of six months. He gave history of loss of appetite and weight loss of 5 kg over a period of six months. He complained of progressive breathlessness on exertion for a period of one month. He gave no history of cough, expectoration, fever, wheeze or hemoptysis. He did not give any history of trauma.\nHe was working as a casual laborer in the agriculture sector. He consumed alcohol on at least five days in a week and smoked at least two packets of beedis in a week.\nNine months back he was admitted to a hospital for treatment of acute abdominal pain. A diagnosis of acute on chronic calcified pancreatitis was made. The most probable cause for the chronic pancreatitis was due to excessive alcohol intake by the patient. A pancreatoduodenostomy was performed on him. He remained asymptomatic for a period of three months. A follow-up ultrasound done after three months showed multiple calcification of the head of the pancreas with bulky tail, and minimal ascites and one old calcified granuloma in the right lobe of the liver. He was put on a low-fat diet, small frequent feeds and received pancreatic enzyme supplements from the time he was operated upon.\nOn examination he was thin built and emaciated and was systemically well. There were no palpable lymphadenopathies. He had bilateral pitting pedal edema. On chest examination there was diminished movement of the right lower hemithorax when compared to the left. Percussion of the right hemithorax yielded a dull note in the right infraaxillary and infrascapular areas which persisted on deep inspiration. On auscultation diminished breath sounds in the right basal regions were apparent. On palpation his abdomen was distended, epigastric tenderness was present and bowel sounds were heard. Examinations of other systems were unremarkable.\nHis hemogram revealed low hemoglobin of 9.2 mg/dl and elevated erythrocyte sedimentation rate of 32 mm in half hour. Renal and liver function tests were within normal limits. Sputum smear examination for acid-fast bacilli was negative in the two samples obtained. The result of the Mantoux test done with 5 TU and read after 48 h was 0 mm. Peripheral smear examination for microfilaria was negative. Chest skiagram revealed apparent elevation of right hemidiaphragm with lateral peaking, a heterogeneous opacity in the right lower zone and loss of lung volume on the right hemithorax. A lateral decubitus view revealed tracking of fluid.\nUltrasonogram of chest was done and pleurocentesis was performed at the site marked for pleural fluid aspiration. The pleural fluid aspirated was milky white in color and odorless [ and ].\nWith pleural fluid triglyceride >110 mg/dl and pleural fluid to serum cholesterol ratio less than 1 a diagnosis of chylothorax was made.[] Pleural fluid cytology was negative for malignant cells. Ziehl-Neelsen staining of pleural fluid smear was 3 plus positive for AFBs []. Computed tomography (CT) scan of the chest showed right-sided hydrothorax with partial collapse of the right lower lobe and fluid in minor fissure []. CT scan of abdomen was suggestive of acute on chronic pancreatitis with ascitis. Ascitic fluid was so minimal that ascitic fluid aspiration could not be done. It did not reveal any evidence of mass lesion or enlarged lymph nodes.\nThe patient was started on antituberculous treatment with a four-drug regimen with isoniazid, pyrazinamide, rifampicin and ethambutol. He did not give consent for intercostal drainage or any surgical or interventional procedure, hence pleural aspiration was done in a staggered manner in three sittings with 500 ml being aspirated in each sitting. As octreotide was not available in our institution he was put on a low-fat diet, intravenous fluids and monitored. The patient's general condition improved and he was discharged from the hospital after three weeks.