A 12-year-old girl presented with a 2-week history of coryza, cough, poor appetite and localised left sided chest pain. There was no history of fever or notable weight loss. Important aspects of her past medical history included a liver transplant nine years previously for idiopathic liver cirrhosis and subsequent right diaphragmatic repair. She previously had a Broviac  line (long term intravenous catheter) inserted in her left subclavian vein. She had received all her early childhood immunisation including BCG at birth. She had hypertension which was controlled on atenolol. Her immunosuppressive medications included oral prednisone 4mg daily and tacrolimus 2mg daily. She was on co-trimoxazole prophylaxis (60 mg daily) but not on isoniazid (TB) prophylaxis. There was no known household TB exposure. Clinical examination showed a well-nourished child with no evidence of peripheral lymph node enlargement and no other constitutional symptoms. Examination and chest radiograph were in keeping with a left sided pleural effusion, Fig. 1a.
A pigtail intercostal drain (ICD), was inserted and drained an initial 260mls of cream-coloured fluid, Fig. 1b.
Abdominal ultrasound did not reveal ascites. Results of laboratory investigations and pleural fluid analysis are shown in Table 1 and were consistent with a chylous pleural effusion. The child received a combination of antibiotics - initially parenteral ampicillin, gentamicin and cloxacillin for 3 days and changed to oral ciprofloxacin and amoxycillin for 5 days. The ICD was removed after seven days, at which time the daily drainage was now less than 10mls with clinical resolution of presenting symptoms. As part of her investigations, the two induced sputum samples taken for culture and PCR for M. tuberculosis (Xpert MTB/Rif Ultra) were negative for M. tuberculosis, but the from the bronchoalveolar lavage sample, rifampicin sensitive M. tuberculosis complex was detected. Her liver function tests were normal on admission, but she developed a transient transaminitis on commencement of first line anti-TB medications (isoniazid, rifampicin, ethambutol and pyrazinamide). This resolved with drug withdrawal. The very raised liver enzymes were attributed to rifampicin and pyrazinamide side effects and thus she was then recommenced on the alternative regimen of 300mg of isoniazid, 400mg of ethambutol, 500mg of ethionamide, and 375mg of levofloxacin. She was additionally commenced on medium chain triglyceride diet by the dieticians. She did well on this therapy and has continued to do well on follow-up, with complete clinical resolution of chest symptoms.