“CHYLO,” IS IT ME YOU'RE LOOKING FOR? A CASE OF TRANSUDATIVE CHYLOTHORAX

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chylothorax is an uncommon type of pleural effusion which is usually exudative in nature. Transudative chylothoraces are an exceedingly rare entity, about 40% of which can be attributed to liver cirrhosis. CASE PRESENTATION: A 69-year-old female with hypertension, IDDM, and NASH/liver cirrhosis, presented with 5 days of shortness of breath and increasing abdominal girth. Examination revealed an obese, ill-appearing female, with stable vital signs, tachypnea requiring 4 L nasal cannula, diminished breath sounds over RM and RL lobes with dullness to percussion, ascitic abdomen without tenderness, without jaundice or other stigmata of liver disease. Laboratory panel was significant for lactic acidosis of 5 mmol/L and hypoalbuminemia. Imaging revealed a large right-sided pleural effusion and moderate ascites. She received aggressive IV fluids, empiric antibiotics, and underwent diagnostic thoracentesis consistent with a transudative effusion. Pleural fluid revealed a “milky” substance; triglyceride level was therefore checked with a value over 200 mg/dL. Her gram stain and culture were negative. Cytology was unremarkable. Patient had no history of trauma or surgeries. CT imaging had no evidence of lymphadenopathy or chronic lung changes. Echocardiogram ruled out CHF and pericarditis. A rheumatic panel was negative. There was no eosinophilia to suggest a parasitic infection. Quantiferon was negative. Paracentesis could not be performed due to small volume of ascites. Chest tube was placed for symptom relief. Given drainage of over 1 L output per day, total parenteral nutrition (TPN), chyle leak diet, and octreotide were started. Chest tube was removed after 10 days given decreasing output. Repeat pleural analysis showed a triglyceride level of 17 mg/dL. TPN was stopped and she was transitioned to a regular diet. Her chylothorax was attributed to liver cirrhosis. She was started on diuretics and discharged home with close follow-up. DISCUSSION: Emphasis must be placed on reviewing all aspects of the pleural fluid analysis including color, with chylothorax on the differential. Transudative chylothorax formation likely occurs due to chylous ascites transmigration through the diaphragm, with cirrhotic portal hypertension causing increased pressure in the thoracic duct. Once trauma is eliminated, malignancy, CHF, SVC obstruction, infections, sarcoidosis, and rheumatologic causes should be ruled out. Treatment relies on decreasing thoracic duct volume and inhibiting intestinal chyle absorption via somatostatin analogues, thoracentesis, and diet. Diuretics and transjugular intrahepatic portosystemic shunting were further treatment options for our patient given her liver cirrhosis. CONCLUSIONS: As transudative chyloraces are rare, clinicians may fail to recognize cirrhosis on the differential and fail to treat the underlying cause. Reference #1: Bhardwaj, Himanshu, et al. “Transudative Chylothorax in a Patient with Liver Cirrhosis: A Rare Association.” Heart & Lung, vol. 44, no. 4, 1 May 2015, pp. 363–365., doi:10.1016/j.hrtlng.2015.03.008. Reference #2: Mukherjee, Arindam, et al. “Transudative Chylothorax: an Uncommon Illness Due to a Common Cause.” BMJ Case Reports, 19 Jan. 2018, doi:10.1136/bcr-2017-223158. Reference #3: Schild, Hans H., et al. “Treatment Options in Patients With Chylothorax.” Deutsches Aerzteblatt Online, vol. 110, no. 48, 2013, pp. 819–826., doi:10.3238/arztebl.2013.0819. DISCLOSURES: No relevant relationships by Robert Gallagher, source=Web Response No relevant relationships by Loren Inigo-Santiago, source=Web Response No relevant relationships by Polina Pinkhasova, source=Web Response