Case Presentation:
A 35 years old lady, not known to have chronic medical illness.
Presented to the hospital with chief complaint of left sided neck
swelling and pain of 2 days duration. She didn’t have a history of
fever, cough, weight loss, haemoptysis, chest pain or shortness of
breath. The patient reported no previous history of tuberculosis in the
family or any sick contacts, and this was the first time to have such
symptoms. The patient is a reformed smoker and drinks socially. There
was no past history of trauma or any vigorous exercise.
Upon arrival to the emergency room, she was afebrile, blood pressure
104/64 mmgh, respiratory rate 18/minute, pulse rate 83/minute.
Neck examination revealed left supraclavicular swelling, tender but soft
with no palpable lymph nodes, examination of the chest revealed stony
dullness and reduced breath sounds in the basal left zone.
Ultrasonography revealed ill-defined predominantly hyperechoic mixed
echogenic area in the left supraclavicular region, and left sided
pleural effusion.
CT neck and chest revealed diffuse fat stranding and small lymph nodes
noticed in mediastinum giving picture of mediastinitis/ Inflammatory
process involving the left posterior neck muscle and in left pectoralis
muscle with diffused smudged fat plane.
No collection noted in the neck. Mild left pleural effusion suggestive
of chylothorax, figure 1, figure 2.
Laboratory investigations including complete blood count, comprehensive
metabolic profile and C-reactive protein, lipase, thyroid function tests
were all within normal limits.
Serum triglyceride 1.9 mmol/L, normal limit 1.7 to 5.6 mmol/L. Serum
cholesterol 4.1 mmol/L, normal limit 5.2 to 6.2 mmol/L.
Ultrasound guided diagnostic aspiration of the pleural fluid showed
milky alkalotic exudative fluid with predominant lymphocytes,
triglycerides level of 2.39 mmol/l, cholesterol level of 3.4 mmol/l,
negative gram stain and bacterial culture, negative acid-fast bacilli
smear, culture and TB-PCR, and also negative cytology. QuantiFERON was
positive.
The patient’s symptoms started to improve during hospital stay with
symptomatic treatment.
Few days later, the patient underwent repeated CT scan which showed
resolution of most of the pleural effusion with normal abdomen CT
findings, figure 3.
Follow up chest X-ray after one month was unremarkable and the patient
was free of symptoms