Pediatr Radiol (2008) 38:224226 DOI 10.

1007/s00247-007-0634-7

CASE REPORT

Chylothorax as a complication of pulmonary tuberculosis in children

Marie Grobbelaar & Savvas Andronikou & Pierre Goussard & Salomine Theron & Ayanda Mapukata & Reena George

Received: 9 May 2007 / Revised: 29 July 2007 / Accepted: 23 August 2007 / Published online: 11 October 2007 # Springer-Verlag 2007

Abstract Chylothorax is a rare clinical entity characterized by a milky white aspirate with increased triglyceride levels. The commonest aetiology is malignancy and trauma. Pulmonary tuberculosis is an extremely rare cause of chylothorax. Two children with chylothorax and pulmonary tuberculosis are described. One child had bilateral and the other unilateral chylous effusions. Extensive mediastinal and hilar lymphadenopathy was demonstrated. Diseased lymph nodes may infiltrate other intrathoracic structures such as the thoracic duct, and they can also obstruct the cisterna chyli and thoracic duct. A possible explanation for the development of a chylothorax in our patients is 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. Keywords Chest . Tuberculosis . Chylothorax . Children

Introduction Chylothorax is a rare clinical entity characterized by a milky white aspirate with an increased triglyceride level in the fluid [1]. Diagnosis can be made when triglyceride levels in the pleural fluid are >1.2 mmol/l (110 mg/dl) [2]. The commonest aetiology is malignancy (commonly lymphoma) and trauma (due to cardiothoracic surgery) [1, 3]. Other causes include thrombosis of the superior vena cava or subclavian veins, constrictive pericarditis, pulmonary lymphangiomyomatosis, filariasis, Kaposi sarcoma in AIDS, heart failure, amyloidosis, tuberculosis (TB) and sarcoidosis [13]. Chylothorax has been described in a patient infected with the human immunodeficiency virus and pulmonary TB [2]. Chylothorax is a rare complication of TB in both adults and children [47].

Case reports Case 1 A 35-month-old boy presented with a cough. His mother was receiving treatment for pulmonary TB. The chest radiograph showed a large right-sided pleural effusion and multilobar pneumonia. Gastric aspirate was positive for acid-fast bacilli and Mycobacterium tuberculosis was cultured from it. The pleural effusion on the left was tapped and found to be chylous with a triglyceride level of 16.2 mmol/l. CT scan of the chest was performed due to symptoms and signs of airway compression and confirmed a large right-sided pleural effusion (mean attenuation 10.2 HU) as well as a smaller left-sided pleural effusion (Fig. 1). Tuberculous lymphadenopathy was demonstrated

M. Grobbelaar : S. Andronikou (*) : S. Theron : A. Mapukata : R. George Department of Radiology, University of Stellenbosch and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg 7505, South Africa e-mail: docsav@mweb.co.za P. Goussard Department of Child Health, University of Stellenbosch and Tygerberg Hospital, 203 Mullerhof, 15 Belle Ombre Road, Cape Town Tamboerskloof 8001, South Africa

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in the right paratracheal, pretracheal, subcarinal, aortopulmonary window and both hilar regions. The patient was negative for retroviral disease. Case 2 A 14-month-old boy was diagnosed with pulmonary TB (gastric aspirate positive for acid-fast bacilli and Mycobacterium tuberculosis cultured). The child also had tuberculous meningitis and was malnourished. He had been exposed to retroviral disease, but his ELISA test was negative at that stage. A left-sided pleural effusion was visible on the chest radiograph and tapped. It was found to be chylous with a

Fig. 1 Case 1: CT of the thorax in a 35-month-old boy. a A large right-sided pleural effusion (10.2 HU) and a small left-sided effusion are demonstrated. The patient has extensive mediastinal lymphadenopathy: subcarinal (short black arrow), right hilar (open arrow) and aortopulmonary window (long black arrow) nodes are visible. The nodes demonstrate central necrosis with rim enhancement, typically found in tuberculous lymphadenopathy. Thoracic duct compression is likely. b There is extensive right paratracheal lymphadenopathy (white arrow) with compression on the trachea. Nodes are also present in the aortopulmonary window (black arrow). The nodes demonstrate ghostlike (white arrow) and ring (white arrowhead) enhancement. Large right-sided and smaller left-sided effusions are visible. c Coronal reconstruction demonstrates the large right-sided and smaller left-sided pleural effusions. Extensive mediastinal and bilateral hilar lymphadenopathy demonstrating ghost-like and ring enhancement patterns is visible. There is compression of the distal trachea (white arrow), left main bronchus (open arrow) and bronchus intermedius (arrowhead)

Fig. 2 Case 2: CT of the thorax in a 14-month-old boy. a Large subcarinal (open arrow) and left hilar (curved arrow) tuberculous lymphadenopathy with consequent bronchial narrowing are demonstrated. The patient has a left-sided pleural effusion and air-space opacification involving the lingula (solid arrow). b Large left-sided chylothorax with a mean attenuation of 19.8 HU

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triglyceride level of 17 mmol/l. CT scan of the chest was performed due to symptoms and signs of airway compression and confirmed the pleural effusion (mean attenuation 19.8 HU) as well as tuberculous lymphadenopathy in the right paratracheal, subcarinal and both hilar regions (Fig. 2).

obstruction of the thoracic duct by tuberculous lymphadenopathy in the right paratracheal region with subsequent increase in pressure in the surrounding lymphatic system and leaking of chyle into the pleural space [2, 5].

References Discussion Pulmonary TB is an extremely rare cause of chylothorax, with only a few cases reported in the literature [2]. Enlarged lymph nodes are a primary feature in childhood tuberculous disease [4, 8]. The most common location reported for tuberculous lymphadenopathy in the chest is subcarinal, followed by the hila, the anterior mediastinum, the precarinal nodes and the right paratracheal nodes. The subcarinal position harbours the largest nodes, followed by the anterior mediastinum and the right paratracheal position [8]. Tuberculous lymphadenopathy is most common following primary infection in children younger than 35 years of age [6, 8]. Diseased lymph nodes may infiltrate other intrathoracic structures such as the oesophagus, phrenic nerve and thoracic duct [6]. Enlarged lymph nodes can also obstruct the cisterna chyli and thoracic duct [2]. A possible explanation for the development of chylothorax in our two patients is
1. Singh P, Shah KV, Shah NT et al (2005) Chylothorax: a rare presentation of constrictive pericarditis. Indian J Tuberc 52:207 210 2. Singh S, Girod JP, Ghobrial MW et al (2001) Chylothorax as a complication of tuberculosis in the setting of the human immunodeficiency virus infection. Arch Intern Med 161:2621 3. Doerr CH, Allen MS, Nichols FC et al (2005) Etiology of chylothorax in 203 patients. Mayo Clin Proc 80:867870 4. Gie RP, Goussard P, Kling S et al (2004) Unusual forms of intrathoracic tuberculosis in children and their management. Paediatr Respir Rev 5(Suppl A):S139S141 5. Vennera MC, Moreno R, Cot J et al (1983) Chylothorax and tuberculosis. Thorax 38:694695 6. Marais BJ, Gie RP, Schaaf HS et al (2004) A proposed radiological classification of childhood intrathoracic tuberculosis. Pediatr Radiol 34:886894 7. Anton PA, Rubio J, Casn P et al (1995) Chylothorax due to Mycobacterium tuberculosis. Thorax 50:1019 8. Andronikou S, Joseph E, Lucas S et al (2004) CT scanning for the detection of tuberculous mediastinal and hilar lymphadenopathy in children. Pediatr Radiol 34:232236

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