SESSION TITLE: Pleural Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Monday, October 28, 2013 at 04:15 PM - 05:15 PM
INTRODUCTION: Chylothorax is an unusual manifestation of tuberculosis. We report a case of bilateral chylothorax due to Mycobacterium tuberculosis in a HIV patient without any lymphadenopathy.
CASE PRESENTATION: A 29 year old male who recently emigrated from Honduras to Florida presented with shortness of breath and abdominal distension. He initially sought treatment in a different hospital where he was diagnosed with HIV with ascitic fluid positive for AFB. He was started on four drug anti-tuberculin therapy which had to be discontinued due to transaminitis. He was then transferred to our facility for further care. Upon presentation, examination was remarkable for a cachectic appearing male with stable vital signs, absent breath sounds at the left lung base and a distended abdomen with shifting dullness. Based on the examination findings, a CT chest was done that showed a large left pleural effusion with a medium sized right pleural effusion and a military pattern in the lung fields. Bilateral thoracentesis drained a milky white pleural fluid. Pleural fluid analysis on right showed leukocyte count 1980/mm3 (83% lymphocytes), protein 1.7 g/dL, LDH 73 IU/L, glucose 109 mg/dL, triglycerides 355 mg/dL and positive chylomicrons. Left sided fluid showed leukocyte count 1920/mm3 (68% lymphocytes), protein 1.8 g/dL, glucose 118 mg/dL, LDH 214 IU/L and triglycerides 199 mg/dL. Based on the appearance of the fluid and triglycerides level of more than 110 mg/dL, a diagnosis of bilateral chylothorax was made. AFB smear and culture were negative. Bilateral pigtail catheters were placed initially for symptomatic relief of dyspnea. Treatment with reduced fat diet and medium chain triglycerides with subcutaneous octreotide was initiated. Anti-tuberculin therapy was slowly reintroduced once transaminitis resolved. The patient improved symptomatically without any reaccumulation of pleural fluid after the removal of pigtail catheters.
DISCUSSION: Chylothorax is diagnosed when pleural fluid triglycerides exceeds 110 mg/dL. Though chylothorax is mostly exudative, transudative effusions have also been reported. In most cases obstruction of thoracic duct due to tubercular lymphadenopathy leads to leakage of chyle into the pleural space. Unilateral chylothorax without any lymph node enlargement has also been reported. In such cases chylothorax develops due to obstruction of lymphatic flow at a microscopic level.
CONCLUSIONS: To best of our knowledge this is the first case of bilateral chylothorax reported in literature without any lymph node enlargement. Our case would help in addition of another variety in the spectrum of tuberculosis.
Reference #1: Kant S, Verma S, Anand S, Prasad R, Verma R. Development of bilateral chylothorax in a younger female secondary to tuberculosis. Lung India. 2011 Jan- Mar; 28(1):56- 59
Reference #2: Anton PA, Rubio J, Casan P, Franquet T. Chylothorax due to Mycobacterium tuberculosis. Thorax 1995;50:1019
DISCLOSURE: The following authors have nothing to disclose: Amita Singh, Jason Bellardini, Ankur Girdhar, Adil Shujaat, Abubakr Bajwa
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