Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion

A Rare Occurrence of Chylopericardium in a Case of Anterior Mediastinal Mass

A middle-aged gentleman presented with dyspnea and hypotension, accompanied by an anterior mediastinal mass infiltrating the anterior chest wall and a moderate to large pericardial effusion, which upon evaluation revealed chylous fluid. Further investigation diagnosed him with right lung adenocarcinoma infiltrating the chest wall, staged at T4N3M1. The patient subsequently developed cardiac tamponade, necessitating immediate medical intervention. Management of the patient's cardiac tamponade involved pericardiocentesis via an indwelling pericardial catheter, allowing continuous drainage of the chylous fluid. Additionally, the patient was placed on a medium-chain triglyceride diet (MCTD) to reduce chyle production. These interventions resulted in significant symptomatic improvement, stabilizing the patient's hemodynamic status, and alleviating the immediate life-threatening condition. This case highlights the clinical challenges posed by rare presentations such as chylopericardium secondary to malignancy and emphasizes the importance of comprehensive diagnostic evaluation and prompt therapeutic management. The successful outcome, achieved through a combination of pericardial drainage and dietary modifications, underscores the critical role of a conservative approach in managing complex oncological cases with acute complications.

Milky pericardial effusion causing tamponade in a neonate after extracorporeal membrane oxygenation cannulation

Cardiac tamponade is a known life-threatening complication of extracorporeal membrane oxygenation (ECMO), often secondary to hemopericardium from major vascular or cardiac perforation. We present the unique case of a neonate with a milky pericardial effusion causing tamponade after ECMO cannulation, managed successfully with pericardial window. Understanding ECMO physiology and its effect on the classic presentation of tamponade is critical and can prevent delays in diagnosis. While hemopericardium is most commonly seen in these cases, findings of a non-bloody, milky effusion should prompt further workup for infection, chylopericardium or total parenteral nutrition-associated pericardial effusion, as the appropriate management can mitigate immediate and potential long-term sequelae.

A case report of generalized lymphangiomatosis with chylopericardium: the crucial role of magnetic resonance lymphangiography

Background

Chylopericardium due to generalized lymphangiomatosis is a rare clinical entity. Its aetiology and treatment remain unclear.

Case summary

We report one case of a 51-year-old man who was diagnosed with generalized lymphangiomatosis with idiopathic chylopericardium by bilateral inguinal intranodal contrast-enhanced magnetic resonance lymphangiography. Magnetic resonance lymphangiography demonstrated abnormal communications between the pericardial sac and the thoracic duct. The patient with idiopathic chylopericardium was therefore successfully treated by exclusive surgical ligation of the abnormal communications and partial pericardiectomy by thoracotomy. The patient’s postoperative recovery was uneventful, and no recurrence of pericardial effusion occurred during the 13-month follow-up.

Discussion

Magnetic resonance lymphangiography showed a good capability for evaluating the extent of generalized lymphangiomatosis and therefore is helpful for delineating the anatomy of the thoracic duct and identifying chyle leakage and abnormal communications between the thoracic duct and the pericardial sac. This makes a simple ligature of the abnormal communications, instead of thoracic duct mass ligation possible in the treatment of chylopericardium.

Chylopericardium in a child with IgA nephropathy: a case report

BACKGROUND

Chylopericardium effusion is characterized by the accumulation of milky effusion in the pericardium. It is often idiopathic but it can be secondary to trauma, chest radiation, tuberculosis and malignancy. If cardiac tamponade ensues, it becomes life-threatening. Herein we describe chylopericardium tamponade in a child with IgA nephropathy. To the best of our knowledge, this is the first reported case of chylopericardium tamponade in IgA nephropathy.

CASE PRESENTATION

A 6 years old boy with IgA nephropathy presented with dyspnea, orthopnea, pretibial pitting edema, ascites and fever. Muffled heart sounds and hepatomegaly were also noted. Echocardiography and thoracic CT revealed that there was a large volume of hydropericardium. Moreover, the pericardial milky fluid by pericardiocentesis was analyzed and chylopericardium effusion was eventually confirmed. Pericardial drainage was continued and his diet was modified to low fat, rich MCT and high protein. Complete remission was achieved after 3 weeks of this combined treatment.

CONCLUSION

Chylopericardial tamponade could be a rare and life-threatening complication of IgA nephropathy. Etiological analysis is critical for determining the therapeutic approach in patients with pericardial effusion.

Primary chylopericardium: A case report and literature review

Primary chylopericardium (CP) is a rare clinical condition in which chylous fluid containing high concentrations of triglyceride accumulates in the pericardial cavity. The present study reports a case of CP that was successfully treated by reconstruction surgery of thoracic duct. To improve the ability to diagnosis and treat this rare disease, the current study also systematically extracted 104 reported cases of primary or idiopathic CP from the past 60 years (January 1950 to December of 2015), and reviewed the clinical manifestation, etiology, diagnosis and treatment of these cases. The age at diagnosis varied between 6 weeks and 79 years with a mean age of 27.95±16.50 years. Asymptomatic patients accounted for 39.42% of cases, while the most common initial symptoms were dyspnea (44.23%) and coughing (10.58%). Jugular venous distention and distant heart sound was identified in 23 (22.12%) and 34 cases (32.69%), respectively. Cardiomegaly in X-ray scans was detected in the majority of patients (93.27%). In addition, lymphoscintigraphy and lymphangiography were helpful in identifying the source of chyle. Regarding the etiology, idiopathic cases accounted for 35.56% of the included cases in the present study. The most important cause of primary CP was abnormal connection or accumulation of lymph fluid in the pericardium (37.50%). Conservative therapy included low-fat or medium-chain triglyceride diet, as well as total parenteral nutrition. The majority of patients (71.2%) required surgery for definitive therapy, and thoracic duct ligation was the most preferred surgical procedure, performed in 44.23% of cases. Follow-up was reported in 64 cases, and all patients survived during the mean follow-up period of 12 months. Therefore, it is suggested that surgical management is the most successful treatment method and is associated with a favorable prognosis.