CONSIDERATIONS FOR CHYLOTHORAX IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chylothorax is a rare complication of chronic lymphocytic leukemia (CLL). Diagnosis is challenging due to its rarity and nonspecific clinical presentation. We report a case of CLL-associated chylothorax. CASE PRESENTATION: A 71 year-old woman with no known medical history presented with dyspnea, weakness, and weight loss. Exam was significant for cachexia and respiratory distress with absent left-sided breath sounds. Labs were notable for WBC 376,800 cells/μL (91% lymphocytes and smudge cells), Hgb 7.1g/dL, platelets 557,000 cells/μL, LDH 408U/L, protein 6.6g/dL. A large left-sided pleural effusion was noted on chest radiograph. CT demonstrated a large left effusion with left lung atelectasis, hepatosplenomegaly, and mediastinal and abdominal lymphadenopathy. Peripheral flow cytometry was consistent with CLL (Rai Stage III). Lung ultrasonography demonstrated multiple septations. Thoracentesis and 8-French chest tube placement were performed. Pleural fluid studies: WBC 4,010 cells/μL (61% neutrophils, 34% lymphocytes), protein 4.4g/dL, LDH 568U/L, amylase 35U/L, and triglycerides 49mg/dL. Pleural fluid was sent for cytology and empiric antibiotics were started. Intrapleural alteplase and DNAse were instilled for 6 doses in attempt to reexpand the lung. Initial cytology and cultures were negative. Pleural fluid analysis was repeated hospital day 11, demonstrating triglycerides 189mg/dL and cholesterol 10mg/dL, consistent with chylothorax. Low fat diet, octreotide, chlorambucil and prednisone were initiated. Daily chest tube output was >500mL and she underwent CT venography. Interventional radiology attempted thoracic duct embolization but were unable to successfully cannulate it. Lymphoscintigraphy identified the thoracic duct leak. Cisterna chyli access via groin lymph node was aborted due to distress when the patient was supine. The patient chose to focus on comfort and the chest tube was removed. She was discharged to home hospice. DISCUSSION: Chylothorax from CLL is uncommon, reported in few cases. The rarity may be attributed to infrequent mediastinal lymphadenopathy in CLL.1,2 In the setting loculated pleural effusions, diagnosis may be difficult due to sampling error; chylothorax is diagnosed by pleural fluid triglycerides >110mg/dl. If levels are indeterminate, repeat analysis is warranted if suspicion remains high. Management focuses on treating the underlying disease and implementing a low fat diet with medium-chain triglycerides. Thoracic duct embolization may be an option for poor surgical candidates failing initial therapy.3 CONCLUSIONS: High suspicion for chylothorax must be maintained in CLL patients with pleural effusion to avoid delaying directed intervention. Reference #1: Zimhony et al. Chronic lymphocytic leukaemia complicated by chylothorax. Journal of internal medicine. 1994 Apr;235(4):375-7. Reference #2: Antón E. Chylothorax in hematologic malignancies. Chest. 2005 May 1;127(5):1866. Reference #3: Bender et al. The changing management of chylothorax in the modern era. European Journal of Cardio-Thoracic Surgery. 2015 Mar 1;49(1):18-24. DISCLOSURES: No relevant relationships by Scott Ferrara, source=Web Response No relevant relationships by Yonatan Greenstein, source=Web Response No relevant relationships by Omry Zuckerman, source=Web Response