INTRODUCTION: Chylothorax is an unusual manifestation of tuberculous disease. Very few cases have been reported in the literature. Here we describe a case of tuberculous chylothorax which was diagnosed on mediastinal biopsy.
CASE PRESENTATION: 29-year-old female patient 4 weeks postpartum referred to us with nonresolving left-sided pleural effusion. Initially she presented to her family physician in her last trimester with a 6 weeks history of evening pyrexia, dry cough, anorexia and undocumented weight loss. Her investigations showed raised ESR and bilateral pleural effusion more on left side. Pleural fluid analysis showed lymphocytic exudate. She was started on anti tuberculosis treatment ( 4 drugs regimen, isoniazid, rifampin, ethambutol and pyrazinamide).In our clinic her physical examination was normal except the findings of left side pleural fluid. Keeping in mind of a young postpartum female with history of fever, cough and weight loss, with CXR evidence of bilateral pleural effusion differential diagnosis of Postpartum cardiomyopathy, Connective tissue disorder, Paradoxical increase in Effusion after starting of anti tuberculous treatment, multidrug resistant tuberculosis and Malignant pleural effusion as ? lymphoma were considered.ANA profile was done which was negative and Echocardiogram was also normal. We repeated pleural fluid analysis and inserted chest tube. The gross appearance of the fluid was milky white. The differential of the fluid was WBC = 100/cumm, polymorphs = 2 % ,Lymphocytes = 96 %, Proteins = 6.14mg/dl, ( serum proteins 7.47 ) LDH = 200 u/L, ( serum LDH 321) Triglycerides = 752mg/dl, cholesterol = 58 mg/dl, glucose = 111 mg/dl. Pleural fluid cytology did not reveal any malignant cells. Pleural biopsy result showed non specific inflammation.CT scan of the chest showed multiple enlarged lymph nodes seen in right Paratracheal, Pretracheal, lateral aortic, Anterior mediastinal, aorto pulmonary window, carinal and subcarinal region. Also seen in bilateral prevertebral and paraaotic region.For mediastinal lymph node biopsy thoracic surgeon was involved, who did thracotomy and mediastinal biopsy. Per operatively thoracic duct leakage was seen at multiple sites. Thoracic duct was ligated. Mediastinal biopsy revealed Chronic Granulomatous inflammation with caseation. Patient was continued on antituberculous therapy and currently improving clinically as well as radiologically.
DISCUSSIONS: Chylothorax is characterized by milky white or tubid appearing pleural fluid due to high lipid content consisting of triglycerides that enter the pleural space as chyle mostly from disruption of the thoracic duct. Non traumatic (72%) causes include most commonly lymphoma (about 50% of all chylothoraces). Other causes include Sarcoidosis, lymphagiomyomatosis, Multiple myeloma, Flariasis and tuberculosis. Anecdotal cases of chylothorax due to Mycobacterium tuberculosis have been reported in the literature. In our patient Lymphoma was a major differential, that's why we did mediastinal lymph node biopsy which came out to be chronic granulomatous inflammation with caseation, which is very rare.
CONCLUSION: We have to think of tuberculosis as a possible etiology of Chylothorax in developing countries where tuberculosis is endemic.
DISCLOSURE: Fayyaz Baig, None.