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de Goede B, de Jong L, van Rossem CC, Schep NWL. Traumatic chylothorax: a case report, treatment options and an update of the literature. AME Case Rep 2024; 8:105. [PMID: 39380856 PMCID: PMC11459413 DOI: 10.21037/acr-24-34] [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: 02/19/2024] [Accepted: 05/30/2024] [Indexed: 10/10/2024]
Abstract
Background Chylothorax is an uncommon condition defined by the escape of lymphatic fluid into the pleural space originating from the thoracic duct. Case Description Our case involves a male patient in his 60s who developed traumatic chylothorax after being involved in a bicycle collision. The total body computed tomography (CT) showed multiple fractures of the ribs and spine, including a fracture of the anterior column of the Th12 vertebra. The patient was placed under observation in the intensive care unit and because of the instability of the Th12 fracture operative stabilization was performed with a percutaneous dorsal pedicle screw-rod spondylodesis. One day postoperatively, the patient suffered from acute respiratory distress; vital signs and hemoglobin levels remained stable. CT angiography was performed showing a large amount of fluid in the right pleural cavity. A chest tube was placed and a total of 3 L of fluid was evacuated. The next day a chylous production of 2 to 3 L per 24 hours was observed. Initiation of nutritional management for the patient involved a medium-chain triglyceride (MCT) diet in conjunction with total parenteral nutrition (TPN) administration. Due to the ongoing chylous leakage, despite the MCT diet and TPN, the patient underwent video-assisted thoracic surgery (VATS); the thoracic duct was identified and clipped. In addition, a VATS chemical pleurodesis with talc was performed. The chylous drainage ceased and after a total of 8 weeks the MCT diet was stopped. Conclusions This case report encompasses relevant diagnostic evaluations and the array of medical treatments applicable to a chylothorax resulting from trauma.
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Affiliation(s)
- Barry de Goede
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Louis de Jong
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Niels W L Schep
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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Umar A, Faquih AE, Bilal M, Garner J. Navigating the Labyrinth: Chylothorax and Chylous Ascites Unveiled After Abdominal Surgery for an Exceptionally Rare Tumor. Cureus 2024; 16:e66239. [PMID: 39238722 PMCID: PMC11375108 DOI: 10.7759/cureus.66239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
Schwannomas, originating from the Schwann sheath of peripheral or cranial nerves, are rare tumors commonly found in the head and neck or extremities. Adrenal schwannomas, however, are exceedingly rare, accounting for less than 1% of all adrenal tumors. Here, we present a case of a 31-year-old Caucasian woman diagnosed with an adrenal schwannoma, which was incidentally discovered during imaging studies for an unrelated issue. Following laparoscopic adrenalectomy, the patient developed chylous ascites (CA) and coexistent chylothorax, posing a diagnostic challenge and necessitating a multidisciplinary approach to management.
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Affiliation(s)
- Anam Umar
- Internal Medicine, Ascension St. Vincent's Birmingham, Birmingham, USA
| | - Amber E Faquih
- Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA
| | - Muhammad Bilal
- Internal Medicine, Ascension St. Vincent's Birmingham, Birmingham, USA
| | - Jeffery Garner
- Pulmonary and Critical Care, Ascension St. Vincent's Birmingham, Birmingham, USA
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Wickramasinghe WMMHP, Ranaweera RMSN, Yasaratne BMDG. Disseminated tuberculosis presenting as bilateral chylothorax: A case report. SAGE Open Med Case Rep 2024; 12:2050313X241247410. [PMID: 38638875 PMCID: PMC11025418 DOI: 10.1177/2050313x241247410] [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: 11/10/2023] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Tuberculosis, being an airborne disease with a broad spectrum of symptoms and signs, is a rare cause of chylothorax. Mortality due to tuberculous chylothorax is 6%, and bilateral chylothorax has a higher mortality with a poor prognosis. A previously well 28-year-old male with a household contact history of tuberculosis exposure presented with a 1-month history of shortness of breath, fever, pleuritic chest pain, and constitutional symptoms. He was found to have bilateral chylothorax, generalized lymphadenopathy, hepatosplenomegaly, and miliary nodules in chest x-ray. Sputum acid-fast bacilli, pleural fluid TB PCR (Tuberculosis polymerase chain reaction) and culture became negative. Sputum culture became positive for Mycobacterium tuberculosis at 6 weeks. He had marked clinical and radiological improvement within 2 months of starting anti-tuberculosis treatment. Diagnosis of pleural tuberculosis is difficult as pleural fluid acid-fast bacilli detection has poor sensitivity. It is important to consider tuberculosis in patients with chylothorax and initiate prompt treatment.
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Affiliation(s)
| | - RMSN Ranaweera
- Teaching Hospital Peradeniya, Peradeniya, Central Province, Sri Lanka
| | - BMDG Yasaratne
- Department of Medicine, Teaching Hospital Peradeniya, Peradeniya, Central Province, Sri Lanka
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Akbar A, Hendrickson T, Vangara A, Marlowe S, Hussain A, Ganti SS. Hepatic Chylothorax: An Uncommon Pleural Effusion. J Investig Med High Impact Case Rep 2023; 11:23247096221150634. [PMID: 36644885 PMCID: PMC9846292 DOI: 10.1177/23247096221150634] [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] [Indexed: 01/17/2023] Open
Abstract
An 83-year-old male with chronic obstructive pulmonary disease and liver cirrhosis presented with confusion and dyspnea. On chest X-ray, he had the right mid to lower lung zone white out. Ultrasound-guided thoracentesis drained 1.5 L of milky white pleural fluid which was transudative according to chemical analysis. Transudative chylothorax in liver cirrhosis without ascites is rare, but can happen. When the flow of ascitic chylous fluid into the pleural space equals the rate of ascites production, clinical absence of detectable ascites will occur. Hepatic chylothorax is important and should be kept in differentials when evaluating patients with liver cirrhosis.
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Affiliation(s)
- Aelia Akbar
- Appalachian Regional Healthcare, Harlan, KY, USA
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Vangara A, Haroon M, Kalafatis K, Kolagatla S, Ganti S, Prevatt O. Chylothorax in the Setting of Lung Malignancy. J Investig Med High Impact Case Rep 2023; 11:23247096231192876. [PMID: 37565692 PMCID: PMC10422884 DOI: 10.1177/23247096231192876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/29/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023] Open
Abstract
Chylothorax refers to chyle within the pleural space, which frequently arises from an interruption in the thoracic duct or because of reduced lymphatic drainage. Pleural fluid that is white/milky in appearance, with a triglyceride concentration of greater than 110 mg/dL, strongly supports the diagnosis of chylothorax. Chylothorax is nearly always exudative. Transudative chylothorax is extremely rare and typically presents due to a secondary cause, such as liver cirrhosis, nephrotic syndrome, or congestive heart failure. We present a case of chylothorax that occurs in the setting of lung adenocarcinoma. A 65-year-old African American man with a past medical history of metastatic right lung adenocarcinoma presented with dyspnea and palpitations. He denied fever, orthopnea, and paroxysmal nocturnal dyspnea. Therapeutic drainage of the left pleural effusion resulted in 650 mL of milky-white fluid. Pleural fluid analysis demonstrated a triglyceride concentration of 520 mg/dL, a pleural/serum protein ratio of 0.41, a pleural/serum lactate dehydrogenase (LDH) ratio of 0.26, a total pleural LDH of 127 IU/L, and a cholesterol level of 58 mg/dL. This effusion can be classified as transudative as per Light's criteria and exudative as per Heffner's and pleural cholesterol criteria. A subsequent pleural fluid cytology found malignant cells consistent with lung adenocarcinoma. Malignancy is the most common cause of nontraumatic, exudative chylothorax. Light's criteria misinterpret about 25% of transudative effusions as exudative. Therefore, to minimize this error, a combination of the 3-criterial consideration is ideal.
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Affiliation(s)
- Avinash Vangara
- Appalachian Regional Healthcare Internal Medicine Residency Program, Harlan, KY, USA
| | - Moeez Haroon
- Appalachian Regional Healthcare Internal Medicine Residency Program, Harlan, KY, USA
| | | | - Sandhya Kolagatla
- Appalachian Regional Healthcare Internal Medicine Residency Program, Whitesburg, KY, USA
| | - SubramanyaShyam Ganti
- Appalachian Regional Healthcare Internal Medicine Residency Program, Harlan, KY, USA
| | - Opal Prevatt
- Appalachian Regional Healthcare Internal Medicine Residency Program, Harlan, KY, USA
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An Uncommon Cause of Chylous Ascites in an Infant. Indian J Pediatr 2022; 89:1268. [PMID: 36264414 DOI: 10.1007/s12098-022-04381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/03/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
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Sun JD, Shum T, Behzadi F, Hammer MM. Imaging Findings of Thoracic Lymphatic Abnormalities. Radiographics 2022; 42:1265-1282. [PMID: 35960666 DOI: 10.1148/rg.220040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The lymphatic system plays an important role in balancing fluid compartments in the body. It is disrupted by various disease processes in the thorax, including injury to the thoracic lymphatic duct after surgery, as well as malignancy and heart failure. Because of the small size of lymphatic vessels, imaging of the lymphatics is relatively difficult, and effective imaging methods are still being optimized and developed. The standard of reference for lymphatic imaging has been conventional lymphangiography for several decades. Other modalities such as CT, noncontrast or contrast-enhanced MRI, and lymphoscintigraphy can also demonstrate lymphatic abnormalities and help in treatment planning. Imaging findings associated with lymphatic abnormalities can be seen in the pulmonary parenchyma, pleural space, and mediastinum. In the pulmonary parenchyma, common findings include interlobular septal thickening as well as reversal of lymphatic flow with intravasation of contrast material into pulmonary lymphatics. In the pleural space, findings include chylous pleural effusion and occasionally nonchylous pleural effusion. In the mediastinum, thoracic duct leak, plexiform thoracic duct, lymphatic malformations, and lymphangiectasis may occur. Management of chylothorax includes conservative or medical treatment, surgery, and interventional radiology procedures. The authors discuss thoracic lymphatic anatomy, imaging manifestations of lymphatic abnormalities in the various anatomic compartments, and interventional radiology treatment of chylothorax. Radiologists should be familiar with these imaging findings for diagnosis and to help guide appropriate management. ©RSNA, 2022.
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Affiliation(s)
- Jingshuo Derek Sun
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Thomas Shum
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Fardad Behzadi
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Mark M Hammer
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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