A 32-year-old male who had been working in a cement-manufacturing facility for 6 years (and had stopped a year ago due to illness) presented with complaints of dry cough for the past 1 year with progressively worsening shortness of breath over a period of 6 months. The shortness of breath was exertional and had progressed rapidly over the past 1 month. He also complained of low-grade fever every day for the past 1 month. There was no history of weight loss, loss of appetite, or of contact with tuberculosis.
On examination, he was found to be tachypneic with a respiratory rate of 30 breaths per minute and a pulse rate of 120 per minute with pulse oximetry revealing an oxygen saturation of 84%. His blood pressure was 112/76 mm Hg. Chest auscultation revealed fine bi-basal crepitations.
On presentation, he was anemic with hemoglobin of 11.9 mg/dL with normal leukocyte and platelet counts. His arterial blood gas report [Table 1] showed Type 1 respiratory failure. His chest X-ray was suggestive of bilateral diffuse infiltrates in the middle and lower zone. High-resolution computed tomography (HRCT) chest image revealed calcified mediastinal nodes with centrilobular nodules in upper lobes along with areas of interlobular septal thickening with fibrosis, a right-sided pleural effusion, and ground glass opacities seen in bilateral upper and lower lobes. [Figure 1a and 1b]
He was suspected to have a lower respiratory tract infection on a background of silica-induced lung disease. However, blood and sputum cultures were negative. He was empirically given multiple antibiotics along with noninvasive positive pressure ventilation support. A fiberoptic bronchoscopy was done on high flow oxygen. The gross appearance of the bronchoalveolar lavage (BAL) fluid was normal and cultures sent for BAL fungal, bacterial, tubercular, and Pneumocystis jirovecii workup were negative. Endobronchial biopsy showed only exogenous pigment in the mucosal cells due to pneumoconiosis.
The patient then underwent a computed tomography (CT) guided-biopsy during which he developed worsening of shortness of breath, right-sided chest pain, and absent breath sounds on the same side. Chest X-ray showed a right-sided hydropneumothorax. A right-sided intercostal drain was inserted and this drained fluid which was opaque with a reddish hue [Figure 2]. Biochemical examination revealed an elevated triglyceride level of 898 mg/dL -suggestive of a chylothorax. A lymphangioscintigraphy was planned to identify the cause of the chylothorax but was deferred till stabilization of the patient's condition. The patient's condition initially improved after intercostal drainage with improvement in shortness of breath. However, he subsequently developed high-grade fever from the 5th day of CT-guided biopsy with worsening respiratory failure and new infiltrates on the chest X-ray. The patient also had new onset shock refractory to fluids and maximal inotropes. He was resuscitated as per the institutional protocol and antibiotics were added. Despite best efforts, the patient succumbed to septic shock due to the hospital-acquired pneumonia within 72 h. The transthoracic lung biopsy [Figure 3] showed revealed anthracofibrosis with alveolar proteinosis.