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Chylous Ascites Caused by Sarcoidosis

A postmenopausal 67-year-old black woman came to the emergency department because of a 2-month history of increasing abdominal girth, decreased appetite, early satiety, and a weight loss of approximately 50 pounds over the past year. During the previous 2 days, she had developed lower extremity edema. She also reported a 2-month history of a nonproductive cough unrelieved by cough syrup with codeine. She reported no fever, chills, night sweats, nausea, vomiting, diarrhea, pelvic or abdominal pain, vaginal bleeding, melena, or changes in bowel or bladder habits. The patient’s medical history included hypertension, arthritis, glaucoma, and syphilis diagnosed 7 years previously. She had a persistently elevated rapid plasma reagin (RPR) level caused by prior use of methyldopa. Six years previously, the patient had been diagnosed with bilateral anterior uveitis, which was most likely caused by syphilis. However, the diagnosis of sarcoidosis had also been considered. At that time, she had negative results on a purified protein derivative (tuberculin) skin test and no abnormalities on chest radiography; angiotensin-converting enzyme (ACE) and vitamin D levels had been within normal limits. Two years previously, the patient had been reevaluated because of abnormal results on chest radiography. Physical examination at that time had revealed a left supraclavicular lymph node. A computed tomography (CT) scan of the chest had shown bilateral hilar adenopathy. The patient’s ACE level had been 85 U/L (normal, 8–52 U/L); results on pulmonary function testing (PFT) had been normal. Fine-needle aspiration of the supraclavicular lymph node had revealed histiocytes and rod-shaped organisms staining positive for acid fast bacilli (AFB). Lymph node cultures and sputum stains and cultures had all been negative for any organisms. The patient had received empirical treatment for scrofula for 6 months. Her supraclavicular lymph node had resolved, but her chest radiograph had remained abnormal. The patient had been followed in the pulmonary clinic ever since that time with a diagnosis of interstitial lung disease. Two months previously, the patient had reported a dry, nonproductive cough and increasing abdominal girth. Follow-up PFTs had revealed a new mild restrictive pattern with decreased diffusing capacity. An upper gastrointestinal barium study had revealed extrinsic compression of the stomach. The patient was admitted to the hospital for evaluation. Her medications at admission included ibuprofen, albuterol inhaler, cetirizine, pseudoephedrine, docusate sodium ear drops, and dorzolamide eye drops. She had smoked 2 packs of cigarettes daily for 40 years, quitting 17 years ago, and drank alcohol heavily in the distant past. C