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Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis
IJTB-100; No. of Pages 3 indian journal of tuberculosis xxx (2016) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ indian-journal-of-tuberculosis/
Case Report
Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis Jihen Ben Amar *, Haifa Zaibi, Besma Dahri, Hichem Aouina Charles Nicolle Hospital, Pulmonology Department, Tunisia
article info
abstract
Article history:
Chylothorax is a rare manifestation of tuberculosis. We report a case of spontaneous
Received 17 September 2015
chylothorax due to tuberculosis. A 62-year-old woman was admitted with fever, chest pain
Accepted 24 June 2016
and dyspnea. Chest and abdominal computed tomography revealed a fluid collection with
Available online xxx
necrotic mediastinal and abdominal lymph nodes. Biopsy of lymph nodes by mediastino-
Keywords:
and his pleural effusion also completely resolved.
scopy. The patient was treated with anti-tuberculosis medication. He is clinically improved Chylothorax
# 2016 Published by Elsevier B.V. on behalf of Tuberculosis Association of India.
Tuberculosis Pleural effusion
1.
Introduction
Chylothorax, an uncommon cause of pleural effusion, results from the accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct. The high content of triglycerides and the presence of chylomicrons set the diagnosis of chylothorax. Malignancy and trauma are the leading causes of chylothorax. Lymph node tuberculosis is an exceptional etiology of chylothorax.1,2 We report a case of chylothorax due to lymph nodes tuberculosis.
2.
Case report
A 62-year-old woman was admitted to our department with a one-month history of fever, right-sided chest pain, nonproductive cough and weight loss of 6 kg. She did not give any
history of trauma. On admission, body temperature was 38.5 8C, heart rate was 80/min and body weight was 70 kg. On chest auscultation, breathing sound was decreased on right lower lung. There were no palpable lymphadenopathies. Abdominal examination was normal. A chest radiograph taken on admission showed right pleural effusion (Fig. 1). Initial laboratory results were as follows: white blood cell count 8900/mm3, hemoglobin 14 g/dL, serum total protein 5.9 g/dL, albumin 2.69 g/dL and elevated erythrocyte sedimentation rate of 35 mm in half hour. Renal and liver function tests were within normal limits. Sputum smear examination for acid-fast bacilli was negative in the three samples obtained. The pleural fluid was aspirated, revealed a milky white fluid. The pleural fluid was sent for examination that revealed, protein 75 g/l and total leukocyte count 5500 cells/mm3; differential leukocyte count was neutrophils 5%, lymphocytes 95%, pleural fluid triglyceride 56.09 mmol/l (49.64 g/l) and pleural fluid cholesterol 3, 47 mmol/l (1.34 g/l). Serum triglyceride and serum cholesterol was 0.56 mmol/l and 3.27 mmol/l,
* Corresponding author. Tel.: +216 98656631. E-mail address: [email protected] (J.B. Amar). http://dx.doi.org/10.1016/j.ijtb.2016.06.001 0019-5707/# 2016 Published by Elsevier B.V. on behalf of Tuberculosis Association of India.
Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
IJTB-100; No. of Pages 3
2
indian journal of tuberculosis xxx (2016) xxx–xxx
Fig. 3 – Chest X-ray after treatment. Fig. 1 – Chest X-ray on admission: right pleural effusion.
respectively. The Ziehl–Neelsen stain of the pleural fluid was negative and also pleural fluid culture for pyogenic organisms was sterile. Pleural fluid cytology was negative for malignant cells. Chest and abdominal computed tomography (CT) showed right pleural effusion with necrotic mediastinal and abdominal lymph nodes (Fig. 2). Biopsy of lymph nodes by mediastinoscopy revealed caseating granuloma, and the Bactec culture for M. tuberculosis was also positive in the mediastinal lymph node biopsy specimen. We diagnosed the patient as having lymph nodes TB associated with chylothorax. The patient received anti-TB treatment with standard 6-month antitubercular treatment: a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol was started for 2 months followed by isoniazid and rifampicin for a further 4 months. The patient also was put on a high protein and low fat diet with medium chain triglyceride. Following this, she showed clinical as well as radiological improvement and chylothorax resolved after treatment, and on regular follow-up she had no further symptoms (Fig. 3).
3.
Discussion
Chylothorax is characterized by chyle in the pleural cavities produced by obstruction and disruption of the lymphatic channel. The etiologies of chylothorax can be nontraumatic and traumatic. The most common cause of nontraumatic chylous effusion is a malignancy, such as lymphoma (75% cases) or metastatic carcinoma1,2 and they are related to tumor invading the thoracic lymph duct. Other causes of nontraumatic chylous effusion include idiopathic, congenital anomaly, protein-losing enteropathy and tuberculosis.3 Trauma is the second leading cause of chylothorax, responsible for 25% of cases. Surgery is the most common cause of traumatic chylothorax, especially in operations that mobilize the left subclavian artery. The exact pathogenesis for the development of chylothorax secondary to tuberculosis remains controversial. The enlarged lumber and iliac group of lymph nodes produced obstruction of the cisterna chyli and thoracic duct, as a result of which there was dilatation of the lumbar channels; this was followed by the opening up of collateral anastomoses, many
Fig. 2 – Computed tomography of chest showed a large lymphadenopathy in mediastinum. Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
IJTB-100; No. of Pages 3 indian journal of tuberculosis xxx (2016) xxx–xxx
lymphaticovenous anastomoses existing between the thoracic duct system and the azygos, intercostal, and lumbar veins. The increased pressure in the system resulted in the transudation of chyle into the pleural space. Grobbelaar et al. reported that the possible explanation for the development of a chylothorax is the obstruction of the thoracic duct by tuberculous lymphadenopathy with subsequent increase in pressure in the surrounding lymphatic system and leaking of chyle into the pleural space.4 In our patient, chylothorax developed possibly due to the enlargement of mediastinal lymph nodes, which obstructed the thoracic duct flow and resulted in chyle leakage into the pleural space. The mainstay of the treatment of chylothorax is conservative measures and correcting the underlying causes. The patient received anti-TB medication and nutrition replacement with high protein and low fat meal with medium chain triglycerides. Although some case reports have described the use of octreotide in the management of chylothorax or chylous ascites.5
Conflicts of interest The authors have none to declare.
references
1. Valentine VG, Raffin TA. The management of chylothorax. Chest. 1992;102:586–591. 2. Romero S, Martín C, Hernandez L, et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest. 1998;114:154–159. 3. Cakir E, Gocmen B, Uyan ZS, Oktem S, Kiyan G. An unusual case of chylothorax complicating childhood tuberculosis. Pediatr Pulmonol. 2008;43:611–614. 4. Grobbelaar M, Andronikou S, Goussard P, Theron S, Mapukata A. Chylothorax as a complication of pulmonary tuberculosis in children. Pediatr Radiol. 2008;38:224–226. 5. Shah D, Sinn JK. Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series. Acta Paediatr. 2012;101:. e151-5–19.
Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ indian-journal-of-tuberculosis/
Case Report
Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis Jihen Ben Amar *, Haifa Zaibi, Besma Dahri, Hichem Aouina Charles Nicolle Hospital, Pulmonology Department, Tunisia
article info
abstract
Article history:
Chylothorax is a rare manifestation of tuberculosis. We report a case of spontaneous
Received 17 September 2015
chylothorax due to tuberculosis. A 62-year-old woman was admitted with fever, chest pain
Accepted 24 June 2016
and dyspnea. Chest and abdominal computed tomography revealed a fluid collection with
Available online xxx
necrotic mediastinal and abdominal lymph nodes. Biopsy of lymph nodes by mediastino-
Keywords:
and his pleural effusion also completely resolved.
scopy. The patient was treated with anti-tuberculosis medication. He is clinically improved Chylothorax
# 2016 Published by Elsevier B.V. on behalf of Tuberculosis Association of India.
Tuberculosis Pleural effusion
1.
Introduction
Chylothorax, an uncommon cause of pleural effusion, results from the accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct. The high content of triglycerides and the presence of chylomicrons set the diagnosis of chylothorax. Malignancy and trauma are the leading causes of chylothorax. Lymph node tuberculosis is an exceptional etiology of chylothorax.1,2 We report a case of chylothorax due to lymph nodes tuberculosis.
2.
Case report
A 62-year-old woman was admitted to our department with a one-month history of fever, right-sided chest pain, nonproductive cough and weight loss of 6 kg. She did not give any
history of trauma. On admission, body temperature was 38.5 8C, heart rate was 80/min and body weight was 70 kg. On chest auscultation, breathing sound was decreased on right lower lung. There were no palpable lymphadenopathies. Abdominal examination was normal. A chest radiograph taken on admission showed right pleural effusion (Fig. 1). Initial laboratory results were as follows: white blood cell count 8900/mm3, hemoglobin 14 g/dL, serum total protein 5.9 g/dL, albumin 2.69 g/dL and elevated erythrocyte sedimentation rate of 35 mm in half hour. Renal and liver function tests were within normal limits. Sputum smear examination for acid-fast bacilli was negative in the three samples obtained. The pleural fluid was aspirated, revealed a milky white fluid. The pleural fluid was sent for examination that revealed, protein 75 g/l and total leukocyte count 5500 cells/mm3; differential leukocyte count was neutrophils 5%, lymphocytes 95%, pleural fluid triglyceride 56.09 mmol/l (49.64 g/l) and pleural fluid cholesterol 3, 47 mmol/l (1.34 g/l). Serum triglyceride and serum cholesterol was 0.56 mmol/l and 3.27 mmol/l,
* Corresponding author. Tel.: +216 98656631. E-mail address: [email protected] (J.B. Amar). http://dx.doi.org/10.1016/j.ijtb.2016.06.001 0019-5707/# 2016 Published by Elsevier B.V. on behalf of Tuberculosis Association of India.
Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
IJTB-100; No. of Pages 3
2
indian journal of tuberculosis xxx (2016) xxx–xxx
Fig. 3 – Chest X-ray after treatment. Fig. 1 – Chest X-ray on admission: right pleural effusion.
respectively. The Ziehl–Neelsen stain of the pleural fluid was negative and also pleural fluid culture for pyogenic organisms was sterile. Pleural fluid cytology was negative for malignant cells. Chest and abdominal computed tomography (CT) showed right pleural effusion with necrotic mediastinal and abdominal lymph nodes (Fig. 2). Biopsy of lymph nodes by mediastinoscopy revealed caseating granuloma, and the Bactec culture for M. tuberculosis was also positive in the mediastinal lymph node biopsy specimen. We diagnosed the patient as having lymph nodes TB associated with chylothorax. The patient received anti-TB treatment with standard 6-month antitubercular treatment: a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol was started for 2 months followed by isoniazid and rifampicin for a further 4 months. The patient also was put on a high protein and low fat diet with medium chain triglyceride. Following this, she showed clinical as well as radiological improvement and chylothorax resolved after treatment, and on regular follow-up she had no further symptoms (Fig. 3).
3.
Discussion
Chylothorax is characterized by chyle in the pleural cavities produced by obstruction and disruption of the lymphatic channel. The etiologies of chylothorax can be nontraumatic and traumatic. The most common cause of nontraumatic chylous effusion is a malignancy, such as lymphoma (75% cases) or metastatic carcinoma1,2 and they are related to tumor invading the thoracic lymph duct. Other causes of nontraumatic chylous effusion include idiopathic, congenital anomaly, protein-losing enteropathy and tuberculosis.3 Trauma is the second leading cause of chylothorax, responsible for 25% of cases. Surgery is the most common cause of traumatic chylothorax, especially in operations that mobilize the left subclavian artery. The exact pathogenesis for the development of chylothorax secondary to tuberculosis remains controversial. The enlarged lumber and iliac group of lymph nodes produced obstruction of the cisterna chyli and thoracic duct, as a result of which there was dilatation of the lumbar channels; this was followed by the opening up of collateral anastomoses, many
Fig. 2 – Computed tomography of chest showed a large lymphadenopathy in mediastinum. Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
IJTB-100; No. of Pages 3 indian journal of tuberculosis xxx (2016) xxx–xxx
lymphaticovenous anastomoses existing between the thoracic duct system and the azygos, intercostal, and lumbar veins. The increased pressure in the system resulted in the transudation of chyle into the pleural space. Grobbelaar et al. reported that the possible explanation for the development of a chylothorax is the obstruction of the thoracic duct by tuberculous lymphadenopathy with subsequent increase in pressure in the surrounding lymphatic system and leaking of chyle into the pleural space.4 In our patient, chylothorax developed possibly due to the enlargement of mediastinal lymph nodes, which obstructed the thoracic duct flow and resulted in chyle leakage into the pleural space. The mainstay of the treatment of chylothorax is conservative measures and correcting the underlying causes. The patient received anti-TB medication and nutrition replacement with high protein and low fat meal with medium chain triglycerides. Although some case reports have described the use of octreotide in the management of chylothorax or chylous ascites.5
Conflicts of interest The authors have none to declare.
references
1. Valentine VG, Raffin TA. The management of chylothorax. Chest. 1992;102:586–591. 2. Romero S, Martín C, Hernandez L, et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest. 1998;114:154–159. 3. Cakir E, Gocmen B, Uyan ZS, Oktem S, Kiyan G. An unusual case of chylothorax complicating childhood tuberculosis. Pediatr Pulmonol. 2008;43:611–614. 4. Grobbelaar M, Andronikou S, Goussard P, Theron S, Mapukata A. Chylothorax as a complication of pulmonary tuberculosis in children. Pediatr Radiol. 2008;38:224–226. 5. Shah D, Sinn JK. Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series. Acta Paediatr. 2012;101:. e151-5–19.
Please cite this article in press as: Amar JB, et al. Spontaneous chylothorax revealing a mediastinal and abdominal lymph node tuberculosis, Indian J Tuberc. (2016), http://dx.doi.org/10.1016/j.ijtb.2016.06.001
3