|Year : 2014 | Volume
| Issue : 1 | Page : 37-39
Pseudochylopneumothorax: A rare presentation of reactivation of tuberculosis
Muzafar Ahmed Naik, Tariq Bhat, Irfan Yusuf, Mehmood Qadri
Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences Medical College and Hospital, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||5-Feb-2014|
Muzafar Ahmed Naik
Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar - 190 011, Kashmir
Source of Support: None, Conflict of Interest: None
A 70-year-old male with past history of treated pulmonary tuberculosis presented with clinical, radiological, and laboratory features suggestive of pseudochylopneumothorax and bronchopleural fistula. Acid-fast bacilli (AFB) staining and AFB culture of pleural fluid was positive. Pseudochylothorax is a rare sterile complication of long standing tubercular effusion. Pseudochylothorax in itself can get complicated by reactivation of tuberculosis and bronchopleural fistula. The occurrence of pseudochylopneumothorax due to bronchopleural fistula as in our case is a rare manifestation of reactivation tuberculosis.
Keywords: Cholesterol, psedochylopneumothorax, pseudochylothorax, tuberculosis
|How to cite this article:|
Naik MA, Bhat T, Yusuf I, Qadri M. Pseudochylopneumothorax: A rare presentation of reactivation of tuberculosis. J Assoc Chest Physicians 2014;2:37-9
|How to cite this URL:|
Naik MA, Bhat T, Yusuf I, Qadri M. Pseudochylopneumothorax: A rare presentation of reactivation of tuberculosis. J Assoc Chest Physicians [serial online] 2014 [cited 2019 Sep 16];2:37-9. Available from: http://www.jacpjournal.org/text.asp?2014/2/1/37/126511
| Introduction|| |
Pseudochylothorax or chyliform effusion or cholesterol pleurisy is a pleural effusion characterized by high cholesterol content and milky pleural fluid often with cholesterol crystals seen on microscopy. Three most common causes of pseudochylothorax are tuberculous pleurisy, chronic rheumatoid pleurisy, and therapeutic pneumothorax.
The pathogenesis of pseudochylothorax is not known. The medical literature has always emphasized that a hallmark of pseudochylothorax is the presence of a grossly thickened (fibrotic) pleura, resulting from chronic intense pleuritis although one case of rapid-onset pseudochylothorax associated with tuberculous pleurisy has been reported.  The high concentration of cholesterol in the pleural space is believed to originate from degraded erythrocytes and neutrophils and poor absorption of cholesterol by the thickened pleura. Pseudochylothorax is complicated by number of conditions, the most common of which is reactivation of tuberculosis. These patients usually have positive pleural fluid acid fast staining or positive pleural fluid cultures for Mycobacterium tuberculosis. Also reactivation of tuberculosis can manifest as bronchopleural fistula. We hereby report a case of pseudochylothorax complicated by reactivation of tuberculosis leading to bronchopleural fistula and pseudochylopneumothorax.
| Case Report|| |
Pseudochylopneumothorax in tuberculosis
A 70-year-old male, reformed smoker, known hypertensive for 20 years controlled on treatment, reported to the outpatient department with osmotic symptoms, and paresthesias of bilateral lower limbs, and deranged plasma sugars. On questioning the patient revealed mild breathlessness while climbing stairs for last 1 month.
The patient had a past history of antitubercular treatment (ATT) intake for right-sided pleural effusion 10 years back. After completion of treatment he had symptomatic relief; however, persisted with loculated pleural effusion on chest X-ray and was subsequently planned for surgery in the cardiovascular thoracic surgery (CVTS) department which he had refused. The patient had lost all medical records and remained asymptomatic over these years till he started with the recent symptoms.
On examination, patient was well built, pulse 84/min, blood pressure (BP) 130/80 mmHg temperature 98°F, and respiratory rate of 18 breaths/min. Chest examination revealed signs of hydropneumothorax on right side and neurologic examination revealed distal sensory motor neuropathy, while rest of the systemic examination was unremarkable.
Patients baseline revealed the hemoglobin (Hb) 13.4 g/dL; white blood cell (WBC) 7.4 × 10 9 /L; differential leukocyte count (DLC): Nutrophil (N) 60%, lymphocytes (L) 30%, and mixed 10%; platelets 123 × 10 9 /L; erythrocyte sedimentation rate (ESR) 20 mm/1 st h; urea 34 mg/dl; serum creatinine 1.2 mg/dl; plasma sugar (fasting 142 mg/dl); bilirubin 1.1 mg/dl; serum glutamic oxaloacetic transaminase (SGOT) 32 U/l; serum glutamic-pyruvic transaminase (SGPT) 34 U/L; total protein 7.6 mg/dl; albumin 3.8 mg/dl; and alkaline phosphatase (ALP) 204 U/l. The serum cholesterol 180 mg/dl, triglycerides 274 mg/dl, high density lipoprotein (HDL) 31 mg/dl, and very low density lipoprotein (VLDL) 55 mg/dl. The serum electrolytes were normal. The chest X-ray revealed hydropneumothorax with varied air fluid levels on the right side with pleural-based nodules [Figure 1]a and b. The electrocardiogram (ECG) and ultrasonography (USG) were normal. The contrast-enhanced computed tomography (CECT) chest [Figure 2] showed right-sided loculated hydropneumothorax with pleural thickening and pleural nodules. A diagnostic pleural fluid tap revealed an odorless, thick, turbid fluid with a total leukocyte count (TLC) of 180, DLC of N90L5M5, and lactate dehydrogenase (LDH) 5,130. Empyema was ruled out as no clear supernatant formed once this fluid was centrifuged. Gram stain came negative. AFB stain of this fluid was positive. Acid-fast bacilli (AFB) culture was positive for Mycobacterium tuberculosis. Lipid profile of the pleural fluid revealed cholesterol (CHOL) - 696 mg/dl, TG-703 mg/dl, HDL - 213 mg/dl, and VLDL - 141 mg/dl. The pleural fluid to serum cholesterol ratio was greater than one favoring pseudochylothorax. Patient was put on ATT (World Health Organization (WHO) CAT II) and intercostal tube (ICT) drainage. On the basis of history, examination, and investigations; a diagnosis of reactivation of tuberculosis complicated by bronchopleural fistula and pseudochylopneumothorax was established.
|Figure 1: (a) Chest X-ray showing air fluid level. (b) Chest X-ray showing changing air fluid level|
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|Figure 2: Contrast-enhanced computed tomography (CECT) chest shows loculated pseudochylopneumothorax with pleural-based nodules|
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The course of treatment was complicated by severe sepsis due to secondary bacterial infection of the pleural space and acute renal failure. Despite aggressive antibiotics and other measures the patient finally succumbed to the complication of tube drainage.
| Discussion|| |
Pseudochylothorax, cholesterol effusions, or chyliform pleural effusions are the consequence of long standing pleural effusions. Although the mean duration of pseudochylothorax is 5 years, but some chyliform pleural effusions have developed within a year of onset.  The most common causes of pseudochylothorax are pleural tuberculosis, chronic rheumatoid pleurisy, and therapeutic pneumothorax; there are rare cases secondary to pleural paragonimiasis, echinococcosis, malignancy, or trauma. ,,,
Pseudochylothorax is characterized by high cholesterol content in the pleural fluid; however, some cases can have high (>250 mg per dL) triglycerides level. Similarly, patients with chylothorax have high triglycerides content in the pleural fluid however some cases can have high cholesterol content in pleural fluid. Our patient had raised levels of both triglycerides and cholesterol in the pleural fluid and differentiating pseudochylothorax from chylothorax in such condition can be done by calculating the pleural fluid to serum cholesterol ratio. If the ratio is more than one, as in our case, it supports the diagnosis of pseudochylothorax. The ratio of pleural fluid to serum triglyceride level is more than one in chylothorax, but this ratio makes no relationship in differentiating patients with nonchylous pleural effusion. 
The complications of pseudochylothorax are infections especially reactivation of tuberculosis leading to tubercular empyema, nontubercular empyema, aspergillosis, and respiratory insufficiency. , The association of pseudochylothorax with positive AFB stain and culture as in our case has been reported earlier. In turn, reactivation of tuberculosis can be associated with bronchopleural fistula; thus, adding therapeutic challenge to the treating physician. The diagnosis of bronchopleural fistula as in our case was established clinically by a persistent air leak and changing air fluid levels radiologically [Figure 1]a and b. Our patient had mild symptoms and pseudochylopneumothorax was an incidental finding at the time of evaluation of diabetes; however, despite antitubercular therapy and ICT, the patient developed secondary infection and succumbed to the complications.
Pseudochylothorax is a rare entity and much rarer is pseudochylopneumothorax which invariably indicates reactivation of tuberculosis secondary to bronchopulmonary fistula (BPF). The management of BPF is still a dilemma and fatal.  The management of BPF secondary to tuberculosis is further complicated. However, bronchoscopic management of BPF with intrabronchial instillation of glue is a cost-effective, viable, and safe alternative compared with costly, time-consuming, and high-risk surgical procedures. 
| References|| |
|1.||Nogueras C, Monteagudo M, Vila M, Cabezuelo A, Mariscal D, Berlanga E. Recent-onset tuberculous pleurisy presenting as pseudochylothorax. Am J Med 2002;113:166-8. |
|2.||Inoue Y, Kawaguchi T, Yoshida A, Harada H, Hara H, Yamamoto S, Sakatani M. Paragonimiasis miyazakii associated with bilateral pseudochylothorax. Intern Med 2000;39:579-82. |
|3.||Thewjitcharoen Y, Poopitaya S. Paragonimiasis presenting with unilateral pseudochylothorax: Case report and literature review. Scand J Infect Dis 2006;38:386-8. |
|4.||Garcia-Zamalloa A, Ruiz-Irastorza G, Aguayo FJ, Gurrutxaga N. Pseudochylothorax. Report of 2 cases and review of the literature. Medicine 1999;78:200-7. |
|5.||Wrightson JM, Stanton AE, Maskell NA, Davies RJ, Lee YC. Pseudochylothorax without pleural thickening: Time to reconsider pathogenesis? Chest 2009;136:1144-7. |
|6.||Vaz MA, Teixeria LR, Vargas FS, Carmo AO, Antonangelo L, Onishi R, et al. Relationship between pleural fluid and serum cholesterol levels. Chest 2001;119:204-10. |
|7.||Erkan ML, Atici AG, Findik S. A case of pseudochylothorax. Turkish Respir J 2001;2:23-5. |
|8.||Daraghmeh AH, Al-Qadi MO, DiNino E, Harada S, Ismail A, Casserly B. Pseudochylothorax complicated by empyema in a patient with rheumatoid arthritis. Am J Respir Crit Care Med 2011;183:A2948. |
|9.||Sonobe M, Nawkagawa M, Ichinose M, Ikegami N, Nagasawa M, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000;18:519-23. |
|10.||Chawla RK, Madan A, Bhardwaj PK, Chawla K. Bronchoscopic management of bronchopleural fistula with intra bronchial instillation of glue. Lung India 2012;29:11-4. |
[Figure 1], [Figure 2]