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Shiraishi K, Chesta F, Nishimura Y, Chong CM. Bilateral Renal Vein Thrombosis and Chylous Ascites in Phospholipase A2 Receptor-Associated Membranous Nephropathy: A Case Report. Cureus 2024; 16:e63434. [PMID: 39077230 PMCID: PMC11284508 DOI: 10.7759/cureus.63434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/31/2024] Open
Abstract
Phospholipase A2 receptor (PLA2R)-associated membranous nephropathy is an important cause of nephrotic syndrome that can lead to a variety of systemic manifestations. Chylous ascites and bilateral renal vein thrombosis are rare manifestations in adult nephrotic syndrome, and there have been no reported cases demonstrating both chylous ascites and bilateral renal vein thrombosis in patients with PLA2R-associated membranous nephropathy. Here, we report the first case of PLA2R-associated membranous nephropathy complicated by renal vein thrombosis and chylous ascites successfully treated with anticoagulation and rituximab. A 65-year-old African American male presented with abdominal pain for four days, hematochezia for one day, and lower extremity edema for one year. Blood pressure was 158/73 mmHg and other vital signs were normal. Physical examination revealed abdominal distention, periumbilical tenderness, and bilateral lower extremity edema. Laboratory analysis showed high serum creatinine, hypoalbuminemia, hyperlipidemia, and proteinuria on 24-hour urine chemistry, all consistent with nephrotic syndrome. Abdominal computed tomography scan demonstrated nonocclusive bilateral renal vein thrombosis with ascites. Paracentesis revealed chylous ascites. Continuous heparin infusion was started for thrombosis. Esophagoduodenoscopy and colonoscopy did not reveal a source of bleeding. Serum anti-PLA2R was found positive, suggesting membranous nephropathy. Rituximab, along with warfarin switched from heparin, successfully controlled disease activity. Chylous ascites in nephrotic syndrome is thought to be associated with bowel edema. In our case, we hypothesize that renal vein thrombosis caused lymphatic fluid leakage by increasing lymphatic pressure. The case illustrates the importance of considering membranous nephropathy as a cause of chylous ascites and renal vein thrombosis. Development of lymphatic imaging techniques is warranted to clarify the pathophysiology.
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Affiliation(s)
- Kazushige Shiraishi
- Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, USA
| | - Fnu Chesta
- Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, USA
| | - Yoshito Nishimura
- Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, USA
| | - Christina M Chong
- Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, USA
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2
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de Villa AR, Obeidat O, Auyeung AB, Jaoude JA, Oyetoran A, Cannon K, Okonoboh P. Superior vena cava syndrome presenting as chylothorax. Radiol Case Rep 2023; 18:3824-3827. [PMID: 37663563 PMCID: PMC10474345 DOI: 10.1016/j.radcr.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Chylothorax caused by superior vena cava (SVC) syndrome is a rare but potentially life-threatening complication requiring a multidisciplinary diagnosis and management approach. We present a case of a 27-year-old female with end-stage renal disease who developed chylothorax secondary to SVC syndrome caused by venous stenosis from a tunneled hemodialysis (HD) catheter. The patient had a history of ongoing hemodialysis through a tunneled catheter placed in the right internal jugular vein approximately seven months before presentation. She presented with dyspnea, chest pain, and a large left-sided pleural effusion. A multidisciplinary diagnostic workup and management included 2 thoracentesis, pleural fluid studies, serial radiological tests, right and left heart catheterizations, and blood serum studies with flow cytometry. They revealed that SVC stenosis around the hemodialysis catheter was causing the patient's pathology. The patient underwent veno-plasty of the right SVC and brachiocephalic veins and replacement of HD catheter leading to the resolution of the chylothorax and significant improvement in respiratory symptoms. This report will highlight the approach to diagnosing and managing chylothorax and a review of existing medical literature.
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Affiliation(s)
- Ariel Ruiz de Villa
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
| | - Omar Obeidat
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
| | - Austin B Auyeung
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
| | - Joseph Abi Jaoude
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Transitional Year Residency Program, Gainesville, FL 32605, USA
| | - Anuoluwa Oyetoran
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
| | - Kristen Cannon
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
| | - Peters Okonoboh
- University of Central Florida College of Medicine, Graduate Medical Education 6850 Lake Nona Blvd, Orlando, FL 32827, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL 32605, USA
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3
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Ünal M, Ünal E, Imholz ALT. Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report. J Med Case Rep 2023; 17:75. [PMID: 36869391 PMCID: PMC9985247 DOI: 10.1186/s13256-023-03775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/13/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Chylothorax is a rare condition due to leakage of chyle in the thoracic cavity. When large amounts of chyle leak into the thoracic cavity, it can lead to severe respiratory, immune, and metabolic complications. Chylothorax has many potential underlying etiologies, and the most common causes are traumatic chylothorax and lymphoma. Venous thrombosis of the upper extremities is a rare cause of a chylothorax. CASE PRESENTATION A 62-year-old Dutch man with a medical history of gastric cancer, treated with neoadjuvant chemotherapy and surgery 13 months prior, presented with dyspnea and a swollen left arm. Computed tomography thorax showed bilateral pleural effusion that was more prominent on the left side. The computed tomography scan further revealed thrombosis of the left jugular and subclavian veins and osseal masses suggesting cancer metastasis. Thoracentesis was performed to confirm the suspicion of gastric cancer metastasis. The obtained fluid was milky with a high level of triglycerides, but contained no malignant cells; hence, the diagnosis of the pleural effusion was chylothorax. Treatment with anticoagulation and a medium-chain-triglycerides diet was started. Furthermore, bone metastasis was confirmed with a bone biopsy. CONCLUSION Our case report demonstrates chylothorax as a rare cause of dyspnea in a patient with pleural effusion and a history of cancer. Therefore, this diagnosis should be considered in all patients with a history of cancer with new-onset pleural effusion and thrombosis of the upper extremities or clavicular/mediastinal lymphadenopathy.
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Affiliation(s)
- M Ünal
- Department of Internal Medicine, University Medical Center Groningen UMCG, P.O. Box 30.001, 9713 GZ, Groningen, The Netherlands.
| | - E Ünal
- Department of Internal Medicine, Hospital Group Twente, Almelo, The Netherlands
| | - A L T Imholz
- Department of Internal Medicine, Deventer Hospital, Deventer, The Netherlands
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Bajad P, B A, Dutt N, Niwas R, Garg PK, Khera P, Chauhan NK. Forgotten Chemo-Port Leading to Chylothorax: A Rare Presentation. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022031. [PMID: 35315422 PMCID: PMC8972872 DOI: 10.23750/abm.v93i1.11080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/05/2020] [Indexed: 11/23/2022]
Abstract
Chylothorax is an uncommon cause of pleural effusion in routine clinical practice. Thoracic surgery, trauma and malignancy are the leading causes of chylothorax accounting for more than 90% of cases.1,2 We report this rare case of a middle aged lady with treated carcinoma breast who presented with left-sided chylothorax secondary to subclavian vein and superior vena cava thrombosis caused by a longstanding indwelling chemo-port in the right internal jugular vein. Patient was managed on total parenteral nutrition (TPN) leading to complete resolution of chylothorax.
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Affiliation(s)
- Pradeep Bajad
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Avinash B
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Naveen Dutt
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Ram Niwas
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Pawan Kumar Garg
- Department of Diagnostic & Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Pushpinder Khera
- Department of Diagnostic & Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
| | - Nishant Kumar Chauhan
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan (India)
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5
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Bouche A, De Wispelaere JF, Kayser F, Collinge E, Fourneau H. Chylothorax due to central vein thrombosis treated by venous stenting using a dual approach: A case report. Medicine (Baltimore) 2021; 100:e28100. [PMID: 34889264 PMCID: PMC8663897 DOI: 10.1097/md.0000000000028100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Central vein thrombosis is an uncommon cause of chylothorax, usually secondary to central venous catheterization in association with prothrombotic state causes such as malignancies. In the following case, thrombosis was located in the left brachiocephalic vein and caused recurrent chylothorax resistant to the first line of treatment and successfully treated by percutaneous recanalization using a dual approach. PATIENT CONCERNS A 52-year-old male patient with current follicular lymphoma undergoing treatment and recent history of COVID-19 pulmonary infection was hospitalized for dyspnea. A chest X-ray revealed extensive bilateral pleural effusion. Analysis of the pleural fluid was compatible with a chylothorax. Iodin injected thoracic computed tomography (CT) revealed a complete left brachiocephalic thrombosis extending to the left axillary vein, with no thoracic mass. DIAGNOSES Chylothorax due to left brachiocephalic vein thrombosis. INTERVENTIONS Following an unsuccessful first line of treatment consisting of a low-fat diet, somatostatins and anticoagulation medication, the patient was elected to undergo minimally invasive venous recanalization with stenting. After a first failed attempt of recanalization by femoral access, we successfully crossed the thrombus through brachial access and conducted a dilatation and stenting of the brachiocephalic vein by femoral access, using a "telepheric" method. OUTCOMES During the 4-month follow up, PET-scanner and chest X-ray demonstrated a significant reduction of the pleural effusion, and the patient reported complete clinical recovery. LESSONS Central vein thrombosis is an unusual cause of chylothorax. We report a case of chylothorax complicating a brachiocephalic vein thrombosis successfully treated by percutaneous recanalization and stenting using a dual brachial and femoral approach. No thoracic duct embolization or ligature was required.
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Affiliation(s)
- Arthur Bouche
- Department of Radiology, CHU UCL Namur/Site Godinne, Yvoir, Belgium
| | | | - Françoise Kayser
- Department of Radiology, CHU UCL Namur/Site Godinne, Yvoir, Belgium
| | - Elodie Collinge
- Department of Hematology, CHU UCL Namur/Site Godinne, Yvoir, Belgium
| | - Hadrien Fourneau
- Department of Radiology, CHU UCL Namur/Site Godinne, Yvoir, Belgium
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6
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Obeso A, Romero Vázquez L, Fernández Noya J. Chylothorax and Central Venous Thrombosis: A Difficult and Challenging Relationship. JACC Case Rep 2021; 3:1576-1578. [PMID: 34729503 PMCID: PMC8543159 DOI: 10.1016/j.jaccas.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Andrés Obeso
- Thoracic Surgery Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Laura Romero Vázquez
- Vascular Surgery Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Jorge Fernández Noya
- Vascular Surgery Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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7
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Deogaonkar G, Sinha MD, Jones M, Calder F, Karunanithy N, Qureshi SA. Percutaneous Venous Reconstruction for Central Thrombosis-Associated Chylothorax: A Safe and Efficacious Option. JACC Case Rep 2021; 3:1569-1575. [PMID: 34729502 PMCID: PMC8543144 DOI: 10.1016/j.jaccas.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Central thrombosis–associated chylothorax is underrecognized in children and frequently refractory to conservative management. Central venous catheterizations are the predominate cause. We present 3 cases highlighting endovascular techniques used to treat persistent chylous effusions. (Level of Difficulty: Advanced.)
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Key Words
- CT, computed tomography
- CTaC, central thrombosis–associated chylothorax
- CVT, central vein thrombosis
- IVC, inferior vena cava
- MCT, medium-chain triglyceride
- MPA, main pulmonary artery
- MRI, magnetic resonance imaging
- RPA, right pulmonary artery
- SVC, superior vena cava
- TPN, total parenteral nutrition
- central line
- central vein obstruction
- chylothorax
- chylous effusion
- endovenous reconstruction
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Affiliation(s)
- Ganesh Deogaonkar
- Department of Interventional Radiology, Evelina London Children's Hospital, London, United Kingdom
| | - Manish D Sinha
- Department of Nephrology, Evelina London Children's Hospital, London, United Kingdom
| | - Matthew Jones
- Department of Pediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Francis Calder
- Department of Renal Transplantation, Evelina London Children's Hospital. London, United Kingdom
| | - Narayan Karunanithy
- Department of Interventional Radiology, Evelina London Children's Hospital, London, United Kingdom.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Shakeel A Qureshi
- Department of Pediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
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8
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Barracano R, Scognamiglio G, Palma M, Sica G, Merola A, Borrelli N, Fusco F, Correra A, Ciriello GD, Sarubbi B. Chylothorax Due to Superior Vena Cava Obstruction in a Patient With Complex Congenital Heart Disease. JACC Case Rep 2021; 3:736-739. [PMID: 34317616 PMCID: PMC8311179 DOI: 10.1016/j.jaccas.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/11/2021] [Accepted: 03/05/2021] [Indexed: 11/26/2022]
Abstract
Obstruction of the superior vena cava represents an under-recognized cause of chylothorax in the adult population. Our case report describes the successful conservative management of chylothorax due to bilateral superior vena cava obstruction in an adult patient with complex congenital heart disease. (Level of Difficulty: Beginner.)
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Affiliation(s)
- Rosaria Barracano
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Giancarlo Scognamiglio
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Michela Palma
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Giacomo Sica
- Division of Radiology, Monaldi Hospital, Naples, Italy
| | - Assunta Merola
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Flavia Fusco
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Anna Correra
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
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9
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Tsuruno K, Tobino K, Sakabe M, Okahisa M, Nishizawa S, Yoshimine K, Ko Y, Ide H. Intractable pleural effusion associated with superior vena cava and upper extremity deep vein thrombosis in a patient with advanced lung cancer. Respir Med Case Rep 2020; 30:101094. [PMID: 32518745 PMCID: PMC7270597 DOI: 10.1016/j.rmcr.2020.101094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
Abstract
We herein report a case with intractable pleural effusion attributed to superior vena cava (SVC) and upper extremity deep vein thrombosis in a patient with lung cancer. A 62-year-old woman presented to our hospital with shortness of breath and bilateral upper extremity edema. One year ago, she was diagnosed with stage IVB lung adenocarcinoma with bilateral malignant pleural effusions. A genetic analysis of the cells from pleural effusion revealed an epidermal growth factor receptor (EGFR) point mutation at exon 21 (L858R); since then, she was treated with gefitinib. Although her lung cancer and metastatic lesions had markedly reduced and the tumor cells in the pleural effusion had disappeared, pleural effusion remained. Contrast-enhanced whole-body computed tomography (CT) revealed intravenous thrombosis extending from the SVC to the left brachiocephalic and subclavian veins, and her pleural effusion was attributed to this thrombosis. Anticoagulant therapy with intravenous heparin and oral warfarin was started, nevertheless, the thrombus remained and pleural effusion did not decrease. After the placement of a pleuroperitoneal shunt, her pleural effusion resolved and her symptoms improved. This case highlights the importance of awareness of SVC or upper extremity deep vein thrombosis as a differential diagnosis of intractable pleural effusion in lung cancer patients.
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Affiliation(s)
- Kosuke Tsuruno
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Kazunori Tobino
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan.,Department of Respiratory Medicine, Juntendo University, School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Mitsukuni Sakabe
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Masanobu Okahisa
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Saori Nishizawa
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Kohei Yoshimine
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Yuki Ko
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
| | - Hiromi Ide
- Department of Respiratory Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka, Fukuoka, 820-0018, Japan
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10
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Tiewsoh K, Rathore V, Bhattacharya D, Pandey J, Bhatia A, Dawman L. Chylothorax in a child with nephrotic syndrome. Indian J Nephrol 2020; 30:32-34. [PMID: 32015598 PMCID: PMC6977379 DOI: 10.4103/ijn.ijn_24_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022] Open
Abstract
Chylothorax is an uncommon presentation of venous thrombosis in nephrotic syndrome. We present a case of an 8-year-old boy with nephrotic syndrome who presented with prolonged respiratory difficulty and dry cough. A detailed evaluation revealed left chylothorax secondary to thrombosis of the left brachiocephalic vein. He improved with conservative management including anticoagulation therapy, intercostal chest tube drainage, and dietary modification. This case highlights the need to consider venous thrombosis as a cause of chylothorax in patients with nephrotic syndrome to institute appropriate treatment.
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11
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Gohar A, Jamous F, Meyer N. Chylothorax as a complication of extensive spontaneous left arm DVT. BMJ Case Rep 2019; 12:12/12/e232563. [PMID: 31892625 DOI: 10.1136/bcr-2019-232563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We present a case of right sided chylothorax in the setting of cirrhosis believed to be secondary to extensive venous thromboembolism of the left upper extremity and exacerbated by chylous ascites. Our patient responded to conservative management with anticoagulation and a repeat thoracentesis revealed transformation of the fluid back to straw coloured transudate. We also include a brief discussion of the diagnosis and management of chylothorax.
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Affiliation(s)
- Ahmed Gohar
- Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Fady Jamous
- Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.,Pulmonary & Sleep Medicine, Avera Medical Group, Sioux Falls, South Dakota, USA
| | - Natasha Meyer
- Pulmonary & Sleep Medicine, Avera Medical Group, Sioux Falls, South Dakota, USA
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12
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Bilateral Chylothorax as a Unique Presentation of Pancreaticobiliary or Upper Gastrointestinal Cancer. Case Rep Pulmonol 2019; 2019:9387021. [PMID: 31355038 PMCID: PMC6633922 DOI: 10.1155/2019/9387021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/17/2019] [Indexed: 11/17/2022] Open
Abstract
Chylothorax presents as exudate with lymphocytic predominance and high triglyceride-low LDH levels, usually due to a traumatic disruption of the thoracic duct, possibly iatrogenic. Other causes include malignancy, sarcoidosis, goiter, AIDS, or tuberculosis. Here we present a case of a 66-year-old male who came in with cough and shortness of breath for few weeks. A week earlier, at an ED visit, he was diagnosed with pneumonia based on CT angiogram of the chest without contrast that showed bilateral pleural effusion and bilateral pulmonary infiltrates. The CT-guided placement of bilateral chest tube drained 1160 cc of creamy yellow fluid on the right and 1200 cc of creamy yellow fluid on the left. CT chest/abdomen/pelvis showed bilateral ground-glass opacities within the lungs and possible bony metastasis. A whole-body bone scan showed multiple bony metastatic lesions throughout the skeleton. IR guided bone biopsy suggested upper GI or pancreaticobiliary cancer. Venous ultrasound with Doppler of left upper extremity showed findings suggestive of a nonocclusive DVT of proximal/mid left subclavian vein which is difficult to compress. Eventually, malignancy-related DVT of the left subclavian/brachiocephalic vein was identified as the possible etiology for the bilateral chylothorax.
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13
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Austin A, Al-Faris F, Modi A, Chopra A. A transudative chylothorax associated with superior vena cava syndrome. Respir Med Case Rep 2019; 28:100898. [PMID: 31338288 PMCID: PMC6626116 DOI: 10.1016/j.rmcr.2019.100898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/24/2019] [Accepted: 07/07/2019] [Indexed: 11/04/2022] Open
Abstract
The chylothorax is a lymphocyte predominant protein-discordant exudative pleural effusions with low lactate dehydrogenase and elevated triglyceride levels. Transudative chylothoraces associated with Superior Cava syndrome (SVC) are an extremely rare clinical entity. In this manuscript, we describe a case of transudative chylothorax due to SVC obstruction secondary to thrombosis of a peripheral inserted central venous catheter, which ultimately resolved after endovascular intervention. In our review of the literature, only five cases of transudative chylothorax associated with SVC syndrome were identified with 60% of cases associated with thrombosis and complications due to catheters in the central venous circulation. Treatment of the underlying cause is key to resolution of the chylothorax. Thoracentesis is an initial intervention for diagnostic and therapeutic purposes. Endovascular intervention is the primary mode of treatment for SVC thrombosis and stenting is preferred for malignant causes, however anticoagulation alone has been reported in the resolution of chylothorax. In patients with recurrent chylothorax despite of relief of SVC obstruction, a medium-chain triglyceride diet and octreotide can be prescribed in order to decrease the chyle flow in the thoracic duct. Surgical ligation of the thoracic duct can be considered if medical management and endovascular treatment fails.
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Affiliation(s)
- Adam Austin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Faris Al-Faris
- Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Aakash Modi
- Department of Medicine, Division of Pulmonary Medicine/Interventional Pulmonology, Memorial Sloan Kettering, New York, NY, USA
| | - Amit Chopra
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
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14
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Zhang C, Xi MY, Zeng J, Li Y, Yu C. Prognostic Impact of Postoperative Complications on Overall Survival in 287 Patients With Oral Cancer: A Retrospective Single-Institution Study. J Oral Maxillofac Surg 2019; 77:1471-1479. [DOI: 10.1016/j.joms.2019.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 12/13/2022]
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15
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Beg F, Agrawal T, Guha A. Unplugging the Drain: Treatment of a Rare Late Complication of Cardiac Resynchronization Therapy. Cureus 2019; 11:e4527. [PMID: 31263636 PMCID: PMC6592466 DOI: 10.7759/cureus.4527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Central vein thrombosis (CVT) is a rare cause of chylothorax. We report a patient with chylothorax secondary to CVT, despite being on anticoagulation, who was successfully treated with balloon angioplasty of the occluded vein. A 65-year-old male presented with shortness of breath of one-month duration. He had end-stage heart failure and was on milrinone infusion. Physical exam was consistent with elevated central venous pressure. Chest x-ray showed a large left-sided pleural effusion. Right heart catheterization (RHC) showed normal right atrial pressure and normal pulmonary capillary wedge pressure. Diagnostic thoracentesis was consistent with chylothorax. A venogram revealed bilateral brachiocephalic vein occlusion. The right brachiocephalic vein was recanalized by angioplasty, which led to resolution of pleural effusion. Our case not only highlights the identification of a rare complication of a common device (i.e., cardiac resynchronization therapy defibrillator) used in heart failure patients but also highlights the treatment for this rare but reversible complication.
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Affiliation(s)
- Faheemullah Beg
- Cardiovascular Disease, Houston Methodist Hospital, Houston, USA
| | | | - Ashrith Guha
- Heart Failure and Transplant Cardiology, DeBakey Cardiology Associates, Houston Methodist Hospital, Houston, USA
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16
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Tacoronte Pérez S, Cerón Navarro J, Pastor Colom A, Morcillo Aixelá A. Chylothorax due to Venous Thrombosis in a Double-Lung Transplant Patient. Arch Bronconeumol 2018; 55:381-382. [PMID: 30541670 DOI: 10.1016/j.arbres.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Sergio Tacoronte Pérez
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Jose Cerón Navarro
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Amparo Pastor Colom
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España
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17
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Kho SS, Tie ST, Chan SK, Yong MC, Chai SL, Voon PJ. Chylothorax and central vein thrombosis, an under-recognized association: a case series. Respirol Case Rep 2017; 5:e00221. [PMID: 28250931 PMCID: PMC5325873 DOI: 10.1002/rcr2.221] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/14/2017] [Accepted: 01/24/2017] [Indexed: 01/31/2023] Open
Abstract
Chylothorax is defined as the presence of chyle in the pleural cavity. Central vein thrombosis is an under‐recognized cause of chylothorax in the adult population and is commonly related to central venous catheterization. Case 1 illustrates a patient with AIDS and disseminated tuberculosis with left chylothorax and central vein thrombosis after a month of antituberculosis therapy. Case 2 was a patient with advanced seminoma who presented with left chylothorax and central vein thrombosis while on chemotherapy. Chylothorax resolved with anticoagulation for both cases. Case 3 was a lymphoma patient with central vein thrombosis who developed chylothorax during chemotherapy. Chylothorax resolved with the continuation of anticoagulation and did not recur despite his progressive underlying lymphoma. There was no central venous catheterization in any of these three cases. These cases illustrate the unique association of central vein thrombosis and chylothorax and the importance of anticoagulation in its management.
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Affiliation(s)
- Sze Shyang Kho
- Respiratory Medicine Unit, Department of Medicine Sarawak General Hospital Kuching Malaysia
| | - Siew Teck Tie
- Respiratory Medicine Unit, Department of Medicine Sarawak General Hospital Kuching Malaysia
| | - Swee Kim Chan
- Respiratory Medicine Unit, Department of Medicine Sarawak General Hospital Kuching Malaysia
| | - Mei Ching Yong
- Respiratory Medicine Unit, Department of Medicine Sarawak General Hospital Kuching Malaysia
| | - Sing Ling Chai
- Department of Diagnostic Imaging Sarawak General Hospital Kuching Malaysia
| | - Pei Jye Voon
- Department of Radiotherapy and Oncology Unit Sarawak General Hospital Kuching Malaysia
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