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.
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.