Rare cause of paradoxical worsening of pleural effusion in a patient with tuberculosis

Abstract

A 33-year-old patient, Known case of chronic kidney disease on maintenance dialysis presented with complaints of low-grade fever and weight loss of 2 months duration. Computed tomography (CT) revealed bilateral mild pleural effusion with significant mediastinal and abdominal adenopathy. CT-guided fine-needle aspiration cytology of abdominal lymph nodes and bone marrow culture was suggestive of tuberculosis. The patient was started on four drug anti-tubercular therapy, post 6 weeks of initiation he developed new onset fever and chest X-ray revealed moderate right pleural effusion. Diagnostic thoracocentesis was suggestive of chylothorax. To the best of our knowledge, this is the first case report of chylothorax due to the paradoxical reaction in the HIV-negative tuberculous patient.

Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature

“…Chylothorax increased or developed on ATT alone in 25% (9/36) of the cases, including in 16.7% (6/36) with IRS. However, thoracic duct ligation [12, 14, 20, 24, 36, 40] and octreotide [22, 26, 36] were required in only 17.1% (6/35) and 8.6% (3/35) of the cases, respectively. In all, 94.4% (34/36) of the cases had good resolution of chylothorax and completed treatment successfully; only 5.6% (2/36) died [18, 27].…”

“…The median triglyceride value observed was very elevated at 678 mg/dL (280.25–1,154). Consequently, chylomicrons were reported in only 11.1% (4/36) of the cases, including the index case [9, 24, 40]. …”

“…Table) [6-40]; we excluded 8 reports containing 12 cases [41-49] because neither the full texts nor abstracts were available, as well as another 5 reports with 5 cases because there was no microbiologic or pathologic evidence of TB [50-54]. The cases where full information was not available were treated as “missing data.” There were 20 males and 16 females with a mean age of 39.27 ± 4.13 years; 13.9% (5/36) were children [15, 22, 23, 26].…”

“…The diagnosis of TB was made concurrently with the diagnosis of chylothorax in 72.2% (26/36) of the cases. Chylothorax developed subsequent to a diagnosis of TB on ATT in 27.8% (10/36) of the cases at a median of 6.75 weeks (IQR 4–9) following the initiation of treatment [7, 12-14, 25, 26, 32, 36, 38, 40]. Chylothorax occurred along with an immune reconstitution syndrome (IRS) in 6 (60%; 6/10) of these cases [12, 25, 26, 32, 36, 40], including 3 in immunocompetent individuals [32, 36, 40].…”

“…In a large series of patients with chylothorax ( n = 203), none were reported to have chylothorax due to TB [55]. Our systematic review suggests that chylothorax is a very rare but well-described complication of TB [6-40]. The occurrence of an acute effusion with smooth unthickened pleural surfaces along with demonstration of elevated triglyceride (≥110 mg/dL) and low cholesterol levels (pleural/serum cholesterol <1) or demonstration of chylomicrons by lipoprotein electrophoresis differentiates a chylothorax from a pseudochylothorax [3].…”