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| MEDICAL SCIENCE - CASE REPORT |
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| Year : 2015 | Volume
: 7
| Issue : 5 | Page : 80-82 |
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An unusual case of pseudochylothorax
M Padma Priya, S Dharmic, Aparajeet Kar, V Suryanarayana
Department of Pulmonary Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu, India
| Date of Submission | 31-Oct-2014 |
| Date of Decision | 31-Oct-2014 |
| Date of Acceptance | 09-Nov-2014 |
| Date of Web Publication | 30-Apr-2015 |
Correspondence Address:
Dr. M Padma Priya
Department of Pulmonary Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-7406.155814
 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 |
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]
- Computed tomography chest-right loculated pleural effusion [Figure 2]
- Pleural fluid appearance: Milky White [Figure 3].
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 | |  |
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 | | |
| 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.  |
| 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. [ PUBMED] |
| 3. | Ferguson GC. Cholesterol pleural effusion in rheumatoid lung disease. Thorax 1966;21:577-82. [ PUBMED] |
| 4. | Hillerdal G. Chyliform (cholesterol) pleural effusion. Chest 1985;88:426-8. [ 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. |
| 6. | Goldman A, Burford TH. Cholesterol pleural effusion: A report of 3 cases with a cure by decortication. Dis Chest 1950;18:586-94. [ PUBMED] |
[Figure 1], [Figure 2], [Figure 3]
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