Journal of Pharmacy And Bioallied Sciences

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

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

Correspondence Address:
Dr. M Padma Priya
Department of Pulmonary Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu
India

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.



How to cite this article:
Priya M P, Dharmic S, Kar A, Suryanarayana V. An unusual case of pseudochylothorax.J Pharm Bioall Sci 2015;7:80-82


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 2021 Jan 15 ];7:80-82
Available from: https://www.jpbsonline.org/text.asp?2015/7/5/80/155814


Full Text

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

Pain and swelling of right ankle - 3 monthsRight sided chest pain - 1-monthBreathlessness - 1-monthWeight 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, feverH/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 monthsBowel and bladder movements normal. No h/o substance abuseOccupation: Welder.

General physical examination

Patient conscious and orientedBody mass index: 20.06 kg/m 2 Right ankle is swollen and tender. Ankle movements are painfulPulse: 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 centerChest movements decreased in right hemithoraxDullness in the right mammary, interscapular, infrascapular and infra axillary areasDecreased breath sounds right infraclavicular area, absent breath sounds in the right mammary, infra-axillary, interscapular, infrascapular areasVocal resonance decreased in these areas.

Investigations

Hb - 13.3 g/dlTC - 11,400 cells/mm 3P - 76, L-18, E-6Erythrocyte sedimentation rate - 45 mm/hr,Platelet count - 3,25,000/mm 3Urea - 25 mg/dl, Creatinine- 0.8 mg/dlLiver function test: within normal limitsRandom blood sugar - 110 mg/dlC-reactive protein - negativeHIV - nonreactiveBlood C and S - no growthNo sputum productionRheumatoid factor: negativeComputed tomography spine: Lytic lesion in D10 with paravertebral abscessCXR-PA: Right sided massive pleural effusion [Figure 1]{Figure 1}Computed tomography chest-right loculated pleural effusion [Figure 2]{Figure 2}Pleural fluid appearance: Milky White [Figure 3].{Figure 3}

Pleural fluid analysis

TC - 86 cells/mm 3 P-10, L-90Sugar - 20 mg/dlProtein - 4.8 gm/glLactate dehydrogenase - 2,460 u/lTriglycerides - 87 mg/dlCholesterol - 180 mg/dlGram's stain - pus cells seenAcid-fast bacilli - negativeAdenosine deaminase - 94 u/lC and S - no growthChylomicrons - Negative.

Differential diagnosis

Tuberculous effusionRheumatoid 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

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2Coe 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.
3Ferguson GC. Cholesterol pleural effusion in rheumatoid lung disease. Thorax 1966;21:577-82.
4Hillerdal G. Chyliform (cholesterol) pleural effusion. Chest 1985;88:426-8.
5Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: Implications for pathogenesis and diagnosis. Respiration 1991;58:294-300.
6Goldman A, Burford TH. Cholesterol pleural effusion: A report of 3 cases with a cure by decortication. Dis Chest 1950;18:586-94.