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MEDICAL SCIENCE - CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 5  |  Page : 80-82  

An unusual case of pseudochylothorax


Department of Pulmonary Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu, India

Date of Submission31-Oct-2014
Date of Decision31-Oct-2014
Date of Acceptance09-Nov-2014
Date of Web Publication30-Apr-2015

Correspondence Address:
Dr. M Padma Priya
Department of Pulmonary Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.155814

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   Abstract 

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.

Keywords: Anti-tuberculosis treatment, para-vertebral abscess, pseudochylothorax, tuberculous


How to cite this article:
Priya M P, Dharmic S, Kar A, Suryanarayana V. An unusual case of pseudochylothorax. J Pharm Bioall Sci 2015;7, Suppl S1:80-2

How to cite this URL:
Priya M P, Dharmic S, Kar A, Suryanarayana V. An unusual case of pseudochylothorax. J Pharm Bioall Sci [serial online] 2015 [cited 2020 Nov 24];7, Suppl S1:80-2. Available from: https://www.jpbsonline.org/text.asp?2015/7/5/80/155814

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/m 2
  • 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/mm 3
  • P - 76, L-18, E-6
  • Erythrocyte sedimentation rate - 45 mm/hr,
  • Platelet count - 3,25,000/mm 3
  • 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

    Click here to view
  • Computed tomography chest-right loculated pleural effusion [Figure 2]
    Figure 2: Computed tomography chest-right loculated pleural effusion

    Click here to view
  • Pleural fluid appearance: Milky White [Figure 3].
    Figure 3: Pleural fluid

    Click here to view


Pleural fluid analysis

  • TC - 86 cells/mm 3 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 Top


Pseudochylous effusion or chyliform effusions are uncommon .[1] The two most common causes of pseudochylous effusion are tuberculosis and rheumatoid pleuritis. [2],[3],[4] 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]

 
   References Top

1.
Garcia-Zamalloa A, Ruiz-Irastorza G, Aguayo FJ, Gurrutxaga N. Pseudochylothorax. Report of 2 cases and review of the literature. Medicine (Baltimore) 1999;78:200-7.  Back to cited text no. 1
    
2.
Coe JE, Aikawa JK. Cholesterol pleural effusion. Report of 2 cases studied with isotopic techniques and review of the world literature. Arch Intern Med 1961;108:763-74.  Back to cited text no. 2
[PUBMED]    
3.
Ferguson GC. Cholesterol pleural effusion in rheumatoid lung disease. Thorax 1966;21:577-82.  Back to cited text no. 3
[PUBMED]    
4.
Hillerdal G. Chyliform (cholesterol) pleural effusion. Chest 1985;88:426-8.  Back to cited text no. 4
[PUBMED]    
5.
Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: Implications for pathogenesis and diagnosis. Respiration 1991;58:294-300.  Back to cited text no. 5
    
6.
Goldman A, Burford TH. Cholesterol pleural effusion: A report of 3 cases with a cure by decortication. Dis Chest 1950;18:586-94.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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