|Topic:||28. Pleural Disease / Adult / Case Report / Clinical Problems (CP)|
|Authors:||S.A. Suliman, A. Ramirez, D.R. Nunley; Louisville, KY/US|
Chylothorax is a rare and apparently underappreciated manifestation of cirrhosis resulting from trans-diaphragmatic passage of chylous ascites. Its uniform biochemical characteristics can facilitate its separation from chylous effusions of different etiology, therefore avoiding potentially harmful diagnostic and therapeutic procedures.
The authors present a 49-year-old female with a history on cirrhosis that arrived with dyspnea and left arm fullness. She underwent an initial Chest CT that showed a large right-sided effusion with enlarged supraclavicular lymph nodes. She underwent a therapeutic thoracentesis, and the results yielded a transudative effusion that was consistent with a chylothorax due to a triglyceride level of 146 and cholesterol of 25. Following a detailed history there was no evidence of recent trauma or active malignancy. At this time she was placed on a diet of medium chain triglycerides. Given the increasing suspicion for an under lying malignancy, a supraclavicular LN biopsy was performed and was negative for malignancy. Less than 24 hours later she had near complete re-accumulation of the right effusion and underwent a second thoracentesis with identical biochemical characteristics. Cytology was also performed on the pleural fluid and again was negative for any malignant cells.
Due to the rapid re-accumulation of the effusion, the patient was sent to interventional radiology to undergo a thoracic duct embolization that was unfortunately unsuccessful, and instead had a chest tube placed for symptomatic relief. Extensive imaging revealed scant abdominal ascites that was not amenable to a diagnostic paracentesis. Briefly thereafter, the patient sustained decompensated liver failure and severe metabolic acidosis. In keeping with the patients wishes she was made comfortable and died during this hospitalization.
A complete work up revealed no underlying malignancy, and the final diagnosis was chylothorax secondary to decompensated cirrhosis.
Chylothorax is an infrequent form of pleural effusions usually caused by malignancies or traumas. Cirrhotic patients often have portal hypertension resulting in increased thoracic duct lymph flow, and accounting for 1% of chylothorax cases. This diagnosis is often missed, leading to unnecessary procedures and tests for these patients.