A 60-year-old retired farmer started experiencing gradual distension of the abdomen for the previous 3 months along with low grade fever and significant weight loss. He was investigated and an ascitic tap initially revealed straw colour fluid with ascitic fluid biochemistry, suggesting an exudate, and ascitic fluid cytology revealing lymphocytic pleocytosis. A retroviral screen was negative. He had no history of cirrhosis, abdominal surgery, trauma or tests indicative of cancer (no cells suggestive of malignancy on the ascetic tap or fine needle aspiration cytology (FNAC)).

He was sent home on presumptive antitubercular therapy with an official document that would help him to receive directly observed therapy (DOT) from his local health centre. He was lost to our follow-up and on recent questioning admitted that he had not taken antitubercular therapy as his ascites had subsided spontaneously. However, he admitted to a continuing low grade fever. When he finally returned 2 weeks later he related that he had developed sudden abdominal distension one week previously. Repeat ascitic tap revealed a milky fluid (fig 1).

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Figure 1

Milky ascites.

An ultrasound done soon after revealed multiple enlarged rounded mesenteric lymph nodes, few of which were conglomerated. Ultrasound guided FNAC from the lymph nodes showed acid fast bacilli on Ziehl–Nielsen stain. The patient was started on antitubercular therapy again with the DOT program and this time we will follow him up more meticulously to ensure compliance.

There have been previous case reports of chylous ascites caused by tuberculosis.1 Causes of chylous ascites have been divided into acquired causes such as inflammatory (for example, tuberculosis, acute or chronic pancreatitis, filariasis), neoplastic (particularly lymphomas and disseminated carcinomas from primaries in the pancreas, breast, colon, prostate, ovary, testes, and kidney) and traumatic (for example, following abdominal surgery, stab wounds, gunshot wounds). In children, the most common causes are congenital abnormalities, such as lymphangiectasia, mesenteric cyst, and idiopathic “leaky lymphatics.”2

Follow-up during antitubercular therapy is a major problem in our part of the world, even with the institution of DOT. In 2004 a government designated DOT centre in India reported a 70% cure rate in a study of 112 patients, which was lower than India’s national average cure rate of 83%.3