Chylous Ascites in a Patient With Cirrhosis and Acute Restrictive Cardiomyopathy Due to a Pericardial Cyst

Abstract

Chylous ascites is the accumulation of triglyceride-rich peritoneal fluid from the disruption of the lymphatic system due to damage of the thoracic duct due to injury, surgery, and infection. It can also occur from right heart failure, pericarditis, and cirrhosis. Chylous ascites is rare affecting 1 in 20,000 hospital admissions. Here we report a unique cause of chylous ascites in a patient with both cardiac and hepatic diseases. A 53 year-old gentleman with alcoholic cirrhosis decompensated by ascites and hepatic encephalopathy presented in undifferentiated shock requiring vasopressors. Initially he was presumed to be in septic shock from spontaneous bacterial peritonitis with paracentesis demonstrating 410 granulated cells and no triglycerides. The patient was prescribed Ceftriaxone and his clinical condition stabilized. Repeat paracentesis demonstrated decreased granulated cells and a triglyceride count greater than 200 mg/dL. A chest x-ray revealed a calcified pericardium and a subsequent cardiac MRI demonstrated a 13 x 7.5 cm extrinsic mass compressing the right ventricle and right atrium. Unfortunately, the patient's white blood cell continued to rise and vasopressor support escalated, although blood cultures remained negative. The patient underwent a coronary angiogram and a CTA of the chest for pre-operative evaluation for excision of this mass. He consequently developed worsening renal function and was placed on continuous veno-venous hemofiltration (CVVH). Despite aggressive vasopressor support and broad spectrum antibiotics, the patient continued to clinically deteriorate, and passed away. An autopsy was performed that demonstrated a 14 cm pericardial cystic mass with associated mural calcifications and acute inflammation consistent with active infection. This case highlights a rare, multifactorial cause of chylous ascites. This patient had a large calcified pericardial cyst compressing his right ventricle and right atrium leading to the development of chylous ascites due to increased hepatic venous pressure and hepatic lymph production. The large mass also caused right-sided heart failure with constrictive physiology, thus impairing hepatic lymph drainage. He had hepatic ascites chronically but never developed chylous ascites prior to the heart failure. This case highlights some of the many causes of chylous ascites and demonstrates that patient can have multiple coincident etiologies of a single manifestation of a disease.