An unusual case of pseudochylothorax.

A 25-year-old male patient presented with right-sided pleuritic chest pain and pain in the ankle. Radiological investigations revealed a right sided pleural effusion, lytic lesion in spine D10 with paravertebral abscess. Pleural fluid analysis showed elevated lactate dehydrogenase, adenosine deaminase, increased triglycerides, cholesterol, and no chylomicrons. Hence, a diagnosis of pseudochylothorax secondary to tuberculosis was made. Pleural fluid was drained by tube thoracostomy, decortication was done to improve the lung function and patient was started on anti-tuberculosis treatment (ATT). Patient improved with ATT. Pseudochylous effusion or chyliform effusions are uncommon. <200 cases has been reported in the international literature. The possibility of tuberculosis has to be considered in diagnosis and treatment of such cases. Here, we present a case of tuberculous pseudochylous effusion.

A 25-year-old male patient came with complaints of:

Pain and swelling of right ankle – 3 months

Right sided chest pain – 1-month

Breathlessness – 1-month

Weight loss – 1-month.

History of presenting illness

Pain and swelling over the lateral aspect of Right ankle, insidious in onset and gradually progressing. Right-sided pleuritic chest pain for 1-month.

Breathlessness for 1-month, insidious in onset, gradually progressed from Grade I to Grade II (modified medical research council). Breathlessness increased in left lateral position. No c/o paroxysmal nocturnal dyspnea, orthopnea.

No c/o cough, fever

H/o Weight loss, 5 kg in 3 months.

Past history

Patient has taken oral analgesics for ankle pain but found no improvement in pain. No h/o tuberculosis, diabetes mellitus, and rheumatic fever.

Personal history

H/o loss of appetite for 3 months

Bowel and bladder movements normal. No h/o substance abuse

Occupation: Welder.

General physical examination

Patient conscious and oriented

Body mass index: 20.06 kg/m2

Right ankle is swollen and tender. Ankle movements are painful

Pulse: 80 bpm, blood pressure: 110/80 mmhg, respiratory rate: 22/min, Temp: Normal, Spo2: 94% at room air.

Respiratory system examination

Trachea is in the center

Chest movements decreased in right hemithorax

Dullness in the right mammary, interscapular, infrascapular and infra axillary areas

Decreased breath sounds right infraclavicular area, absent breath sounds in the right mammary, infra-axillary, interscapular, infrascapular areas

Vocal resonance decreased in these areas.

Investigations

Hb – 13.3 g/dl

TC – 11,400 cells/mm3

P – 76, L–18, E-6

Erythrocyte sedimentation rate – 45 mm/hr,

Platelet count – 3,25,000/mm3

Urea – 25 mg/dl, Creatinine– 0.8 mg/dl

Liver function test: within normal limits

Random blood sugar – 110 mg/dl

C-reactive protein – negative

HIV – nonreactive

Blood C and S – no growth

No sputum production

Rheumatoid factor: negative

Computed tomography spine: Lytic lesion in D10 with paravertebral abscess

CXR-PA: Right sided massive pleural effusion [Figure 1]

Figure 1

Chest X-ray-posteroanterior: Right sided pleural effusion

Computed tomography chest-right loculated pleural effusion [Figure 2]

Figure 2

Computed tomography chest-right loculated pleural effusion

Pleural fluid appearance: Milky White [Figure 3].

Figure 3

Pleural fluid

Pleural fluid analysis

TC – 86 cells/mm3 P-10, L-90

Sugar – 20 mg/dl

Protein – 4.8 gm/gl

Lactate dehydrogenase – 2,460 u/l

Triglycerides – 87 mg/dl

Cholesterol – 180 mg/dl

Gram's stain – pus cells seen

Acid-fast bacilli – negative

Adenosine deaminase – 94 u/l

C and S – no growth

Chylomicrons – Negative.

Differential diagnosis

Tuberculous effusion

Rheumatoid pleurisy.

Treatment

Effusion is drained through tube thoracostomy. Due to lack of lung expansion, patient underwent the decortication. In view of ankle synovitis, lytic lesion in vertebra with paravertebral abscess, empyema thoracis, and patient was diagnosed to have disseminated tuberculosis and started on 4 drug regimen of anti-tuberculosis treatment (ATT).

Outcome and follow-up

Patient improved with ATT. Patient remained symptom-free during the follow-up period.

Discussion

Pseudochylous effusion or chyliform effusions are uncommon.[1] The two most common causes of pseudochylous effusion are tuberculosis and rheumatoid pleuritis.[234] The exact pathogenesis of pseudochylous effusion is not known.[5] The diseased pleura may result in accumulation of cholesterol in the pleural fluid.[2] The diagnosis of pseudochylothorax is established by pleural fluid analysis. Presence of cholesterol crystals in the effusion is diagnostic of pseudochylous effusion. The possibility of tuberculosis should always be considered in a patient with pseudochylothorax. A multidrug regimen tuberculosis treatment is needed. Draining of effusion improves exercise tolerance.[4] Decortication is showed to improve the lung function.[6]