An HIV-exposed uninfected 20-month-old boy presented to Chris\nHani Baragwanath Academic Hospital in Johannesburg, South Africa,\nwith a 2-day history of shortness of breath, cough and noisy breathing.\nHe had also experienced night sweats, fever and vomiting for a week.\nTwo weeks prior to this presentation, he had been diagnosed with\nbacteriologically unconfirmed PTB at a primary healthcare clinic and\nwas empirically started on a four-drug antituberculosis treatment\nregimen (rifampicin, isoniazid, pyrazinamide and ethambutol). The\ndiagnosis was based on a chest X-ray and a positive Mantoux\ntest. His father (a household contact) had been diagnosed with PTB,\nand had been on first-line antituberculosis treatment for 4 months. \nThe boy had had normal growth and development up to 1 year of age,\nbut had subsequently lost weight, and fallen from a weight-for-height\nz-score +2 to the median over the preceding 8 months.\nOn admission, he was apyrexial, tachycardic and in moderate\nrespiratory distress, with oxygen saturations of 97% in room air. He\nhad marked chest wall indrawing and bilateral posterior cervical\nand axillary lymph nodes (<0.5 cm in diameter). He was clinically\nhyperinflated, with bilateral wheezing. The rest of his clinical\nexamination was normal.\nHe was diagnosed with viral bronchiolitis, and therefore a chest\nX-ray was not performed. He was started on oxygen and hypertonic\nsaline nebulisation. He responded poorly to this initial treatment\nand was therefore started on oral corticosteroids and amoxicillin on\nday 2 of hospitalisation, and his first-line antituberculosis treatment\nwas continued. Gastric aspirate samples for microscopy for acid-fast\nbacilli, Xpert MTB/RIF (Cepheid, USA) and culture for mycobacteria\nwere negative.\nDuring his hospital admission period his wheezing persisted,\nand he remained in moderate respiratory distress. On the fifth day\nof admission, he developed percussion dullness and absent breath\nsounds over the right hemithorax.\nA chest X-ray at this point revealed a large right-sided pleural\neffusion . A computed tomography scan of the chest revealed\nhilar lymphadenopathy and a large right-sided pleural effusion. The\nthoracic duct could not be visualised. Diagnostic pleurocentesis\nconfirmed a chylothorax. It was suspected that tuberculous lymph\nnodes had eroded the thoracic duct causing the chylothorax, and\ntherefore a bronchoscopy was performed, which revealed caseating\nlymph nodes in the right main bronchus suggestive of TB, and 90%\nobstruction of the left main bronchus. The Xpert MTB/RIF (Cephaid,\nUSA) test on a bronchoalveolar lavage specimen identified rifampicinresistant Mycobacterium tuberculosis. Gastric aspirates, pleural fluid\nand bronchoalveolar lavage samples were all smear-negative for acidfast bacilli and mycobacterial culture-negative.\nThe chylothorax was managed with a low-fat diet (with additional\nmedium-chain triglycerides), therapeutic taps for worsening\nrespiratory distress and an octreotide infusion. The boy was\ncommenced on multidrug-resistant TB (MDR-TB) treatment\n(amikacin, levofloxicin, ethionamide, terizidone, pyrazinamide,\nethambutol and high-dose isoniazid) and oral steroids.\nFor further management, he was transferred to a hospital dedicated\nto the care of MDR-TB patients. One month later, he showed marked\nclinical improvement, with almost complete radiological resolution of\nthe chylothorax, and reduced hilar lymphadenopathy . The\nfull case overview is shown in .
An 18-year-old, HIV-negative, male patient was admitted to the hospital complaining of nonquantified weight loss and abdominal pain over a 3 month period. Physical findings included disseminated cutaneous lesions and paraparesis of the lower extremities. Diagnosis of acute paracoccidioidomycosis was confirmed through KOH (potassium hydroxide) direct visualization of typical yeast structures of Paracoccidioides spp. in samples from the skin biopsy (). Abdominal ultrasound revealed extensive peritoneal lymph node involvement, and computerized tomography (CT) with intravenous contrast of the brain revealed a pontomesencephalic lesion (2.3 cm) with ring-enhancement (, white arrow). Chest radiography was normal ().\nLiposomal amphotericin B was administered for 90 days, followed by sulfamethoxazole/trimethoprim. The patient responded well to therapy, but after approximately 1 year of drug therapy, he developed painful abdominal bloating and umbilical protrusion (). Abdominal CT with oral and intravenous contrast revealed a 11.1 by 6.5 cm ovoid lesion in the anterior abdominal wall (, white arrow) that was previously reported as a similar cystic image by ultrasound a month before.\nWhat is your diagnosis?