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November 26, 2001

Chylothorax as a Complication of Tuberculosis in the Setting of the Human Immunodeficiency Virus Infection

Arch Intern Med. 2001;161(21):2621. doi:

Chylothorax is an infrequent disorder associated most commonly with neoplasm or trauma to the thoracic duct. Nontraumatic chylothorax is uncommon. Several etiologies have been cited, of which tuberculosis is exceedingly rare. Herein, we describe a patient who developed chylothorax as a complication of pulmonary tuberculosis in the setting of the human immunodeficiency virus infection.

A 29-year-old African American male infected with human immunodeficiency virus presented with progressive dyspnea of 2 weeks' duration associated with a nonproductive cough, progressive weight loss, fever, and chills. The patient was diagnosed as having active pulmonary tuberculosis 4 months prior to admission and had received only 2 months of antituberculous therapy ending because of noncompliance. On admission he appeared cachectic and tachypneic with an oral temperature of 39°C and an arterial oxygen saturation of 97% in room air. Chest examination revealed crackles and expiratory wheezes throughout the lung fields. The right base was dull to percussion but no bronchial breath sounds were auscultated. Heart examination revealed only distant sounds. The remainder of the examination was within normal limits. Chest radiography showed bilateral infiltrates and pleural effusions. He was started on empirical therapy for Pneumocystis carinii pneumonia and community-acquired pneumonia. The patient declined bronchoscopy. A computed tomographic scan of the chest confirmed bilateral pleural effusions with mediastinal necrotic lymphadenopathy. Right-sided thoracentesis revealed a milky fluid with a triglyceride level of 2260 mg/dL (25.5 mmol/L) and was negative for cholesterol crystals. The corresponding serum triglyceride level was 45 mg/dL (0.5 mmol/L). A chest tube was placed and continued to drain chylous fluid. He was initially treated conservatively for the chylothorax with dietary fat restriction, total parenteral nutrition, and medium-chain triglyceride supplementation. After 5 days of conservative treatment we opted for surgical intervention. He underwent thoracic duct ligation with pleural peel and lymph node biopsies. Pleural biopsy specimens were positive for Mycobacterium tuberculosis by polymerase chain reaction assay, and all biopsy specimens were negative for malignancy. Sputum smears were positive for acid-fast bacilli and negative for P carinii pneumonia. Antituberculous therapy was started with isoniazid, rifampin, ethambutol hydrochloride, and pyrazinamide. The chylous chest tube drainage resolved 3 days after surgical ligation and follow-up chest radiography 2 weeks later showed resolution of the pleural effusions.

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