A 10-year-old male presented with 3 weeks of chest pain that was worse on the right side, dry cough, poor appetite, fever and night sweats with progressively worsening respiratory distress and weight loss. He was HIV-exposed but un-infected and there was no household TB exposure. He had received all childhood immunizations. His mother had died 4 years previously of an HIV-related illness. The child appeared unwell with examination findings of fever, respiratory distress requiring oxygen; enlarged cervical lymph nodes, mild hepatosplenomegaly, and features consistent with a right sided pleural effusion and left lower lobe pneumonia, confirmed on chest radiograph, Fig. 2a.
Abdominal ultrasound showing multiple splenic micro abscesses (Fig. 2b).
As bacterial empyema was suspected, a pigtail intercostal drain was inserted and drained 330mls of milky-serous fluid (Fig. 2c) which appeared to be pus.
Investigations on pleural fluid and sputum confirmed pulmonary tuberculosis and chylous pleural effusion are shown in Table 1.
The child was treated with intravenous ceftriaxone for 7 days. The pleural drain was removed after 8 days, at which time the daily drainage was now less than 10mls with clinical resolution of presenting symptoms. Tuberculosis was proven on an induced sputum (Xpert MTB/Rif Ultra positive, rifampicin sensitive) and he was commenced on the standard anti-TB medications: isoniazid, rifampicin, ethambutol and pyrazinamide. He was also started on medium chain triglyceride diet. On follow-up, he has done well with complete clinical and radiological resolution of chest symptoms.