A case report of tuberculous chylothorax. / Reporte de un caso de quilotórax tuberculoso.

Tuberculous chylothorax is a rare infectious disease that occurs when the thoracic duct is obstructed. Treatment is directed to the tuberculosis infection. A 55-year-old male, driver, born in Trujillo (Peru) is admitted to the emergency department with increasing dyspnea and a 5-day dry cough. The physical examination revealed vocal fremitus, dullness to percussion, and a vesicular murmur that was decreased on the lower 2/3 of the left hemithorax. The X-ray and the thoracic ultrasound revealed significant left pleural effusion. The thoracocentesis drained fluid identified as chylothorax. Subsequently, a thoracic tube was placed, with a decrease in pleural fluid volume and later normalization of the cytochemical changes. Diagnostic video bronchoscopy was performed with a bronchoalveolar aspirate, revealing acid-fast bacilli. The patient received antituberculosis treatment with a favorable outcome. Tuberculous chylothorax is an important cause of chylothorax to be considered in endemic areas of tuberculosis. Proper treatment of the infection leads to resolution of the disease.

El quilotórax tuberculoso es una patología infecciosa infrecuente, que se produce como consecuencia del bloqueo del conducto torácico. Su tratamiento está dirigido a combatir la infección tuberculosa. Se presenta el caso de un varón de 55 años de edad, chofer, natural de Trujillo-Perú, que acudió a emergencia por disnea progresiva y tos seca de cinco días de evolución. El examen físico reveló frémito vocal, matidez y murmullo vesicular disminuido en 2/3 inferiores del hemitórax izquierdo. La radiografía y ecografía torácica evidenciaron derrame pleural significativo, y la toracocentesis reveló quilotórax. Posteriormente, se colocó un tubo de drenaje torácico, con disminución progresiva del volumen del líquido pleural y cambios citoquímicos. Se realizó videobroncoscopía diagnóstica con aspirado broncoalveolar, revelando bacilos ácido-alcohol resistentes. El paciente recibió tratamiento antituberculoso, con evolución favorable. El quilotórax tuberculoso constituye una causa importante de quilotórax a considerar en zonas endémicas de tuberculosis. El tratamiento adecuado de la infección, conlleva a resolución de la enfermedad.

Reporte de un caso de quilotórax tuberculoso / A case report of tuberculous chylothorax

El quilotórax tuberculoso es una patología infecciosa infrecuente, que se produce como consecuencia del bloqueo del conducto torácico. Su tratamiento está dirigido a combatir la infección tuberculosa. Se presenta el caso de un varón de 55 años de edad, chofer, natural de Trujillo-Perú, que acudió a emergencia por disnea progresiva y tos seca de cinco días de evolución. El examen físico reveló frémito vocal, matidez y murmullo vesicular disminuido en 2/3 inferiores del hemitórax izquierdo. La radiografía y ecografía torácica evidenciaron derrame pleural significativo, y la toracocentesis reveló quilotórax. Posteriormente, se colocó un tubo de drenaje torácico, con disminución progresiva del volumen del líquido pleural y cambios citoquímicos. Se realizó videobroncoscopía diagnóstica con aspirado broncoalveolar, revelando bacilos ácido-alcohol resistentes. El paciente recibió tratamiento antituberculoso, con evolución favorable. El quilotórax tuberculoso constituye una causa importante de quilotórax a considerar en zonas endémicas de tuberculosis. El tratamiento adecuado de la infección, conlleva a resolución de la enfermedad.

Tuberculous chylothorax is a rare infectious disease that occurs when the thoracic duct is obstructed. Treatment is directed to the tuberculosis infection. A 55-year-old male, driver, born in Trujillo (Peru) is admitted to the emergency department with increasing dyspnea and a 5-day dry cough. The physical examination revealed vocal fremitus, dullness to percussion, and a vesicular murmur that was decreased on the lower 2/3 of the left hemithorax. The X-ray and the thoracic ultrasound revealed significant left pleural effusion. The thoracocentesis drained fluid identified as chylothorax. Subsequently, a thoracic tube was placed, with a decrease in pleural fluid volume and later normalization of the cytochemical changes. Diagnostic video bronchoscopy was performed with a bronchoalveolar aspirate, revealing acid-fast bacilli. The patient received antituberculosis treatment with a favorable outcome. Tuberculous chylothorax is an important cause of chylothorax to be considered in endemic areas of tuberculosis. Proper treatment of the infection leads to resolution of the disease.

Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature.

Tuberculosis (TB) is a rare cause of chylothorax. We describe a case and the results of a systematic review of all reported cases of TB-chylothorax. We identified 37 cases of TB-chylothorax. The symptoms at presentation were constitutional (85.7%; 30/35), dyspnea (60.6%; 20/33), and cough (54.5%; 18/33). Chylothorax developed subsequent to the diagnosis of TB in 27.8% (10/36) of the patients, after a median of 6.75 weeks (IQR 4-9). Chylothorax developed during an immune reconstitution syndrome (IRS) in 16.7% (10/36) of the patients, including immunocompetent ones. TB was disseminated in 45.9% (17/37) of the patients at the diagnosis of chylothorax. Chylothorax developed in the absence of any mediastinal lymphadenopathy in 45.9% (17/37) of the patients; 13.5% (5/37) had isolated tubercular empyema alone. The diagnosis of TB was established microbiologically in 72.2% (26/36) and by biopsy alone in 27.8% (9/36) of the patients. Anti-TB treatment (ATT) was administered for a median of 7.57 months (IQR 6-9). Steroids were administered to 22.9% (8/35) of the patients, often for suspected IRS. Thoracic duct ligation and octreotide were required for only 17.1% (6/35) and 8.6% (3/35) of the patients, respectively. In all, 94.4% (34/36) of the patients had resolution of chylothorax and completed treatment successfully; only 5.6% (2/36) died. In conclusion, TB-chylothorax may develop without obvious mediastinal lymphadenopathy and be associated with tubercular empyema alone. TB-chylothorax can develop during treatment of TB due to IRS, even in immunocompetent patients. ATT and dietary manipulation are associated with good resolution and low mortality, and duct ligation is needed for only a small minority of patients.

CHYLOTHORAX IN PARACOCCIDIOIDOMYCOSIS.

A previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions.

Chylothorax and chylous ascites due to Mycobacterium tuberculosis in an AIDS patient whose PCR tested negative.

Mycobacterium tuberculosis as a cause of both chylothorax and chylous ascites is extremely rare. A 46-year-old non-adherent woman with AIDS and pulmonary tuberculosis presented to our clinic with dyspnea, pleuritic chest and abdominal pain. Chest x-ray demonstrated a left pleural effusion. Contrast-enhanced CT showed free abdominal fluid. Thoracentesis revealed a chylothorax, and paracentesis a chylous ascites. AFB staining and PCR for M. tuberculosis (GeneXpert MTB/ RIF Assay) were both negative. Malignant cells cytology also tested negative. Tuberculosis could account for both chylothorax and chylousascites, as she clinically improved when antituberculous drugs were resumed. Even when PCR tested negative, M. tuberculosis should be included in the differential diagnosis because of its therapeutic and prognostic implications. Keywords: Chylothorax, chylous ascites, Mycobacterium tuberculosis, acquired immunodeficiency syndrom, antituberculous drugs.

[Tuberculous chylothorax: case report and review of the literature]. / Quilotórax tuberculoso: caso clínico y revisión de la literatura.

Chylothorax is an unusual manifestation of tuberculous disease. Anecdotal cases of chylothorax due to Mycobacterium tuberculosis have been reported in the literature. We describe a case of tuberculous chylothorax and review the previously published cases. None of these cases was diagnosed by the application of polymerase chain reaction in pleural effusion. This test applied to different specimens has shown high specificity and sensitivity; for this reason, the routine use of this test, on pleural effusion, could be very useful, quick, and few aggressive in the diagnosis of tuberculous chylothorax, especially when chest X-ray is normal.

Rupture of tuberculous spinal abscess resulting in tuberculous empyema and chylothorax.

STUDY DESIGN: Case report with a review of scientific literature. OBJECTIVE: To describe the course of tuberculous spinal disease (Pott's disease) complicated by pyogenic and tuberculous empyema, and chylothorax as there has been an increase in the numbers of notified cases of tuberculosis in the UK(1). To the best of our knowledge, a similar case has not been reported previously in the UK, although there has been a report of bilateral chylothorax associated with Pott's disease. SETTING: A national spinal injuries unit in a Scottish university teaching hospital. METHODS: Review of literature on the chemotherapy of spinal tuberculosis and the role of streptokinase in the treatment of empyema and the relation between spinal tuberculosis, empyema and chylothorax. RESULTS: Although spinal tuberculosis was recognised and treated appropriately with chemotherapy, the patient sustained pleural involvement with later development of both empyema and chylothorax. CONCLUSION: The case highlights the difficulties in the treatment of tuberculosis of the spine inspite of the presence of fully sensitive organisms and early institution of appropriate chemotherapy. In the absence of surgical debridement, the duration and dosage of chemotherapy as practised in the initial period may have to be prolonged into the continuation phase. The thoracic duct can be damaged either because of extension of the tuberculosis itself or because of instillation of intrapleural streptokinase for treatment of pleural empyema leading to chylothorax. There is a need for randomised trials of intrapleural streptokinase treatment in tuberculous empyema.