DEATH BY CHYLOTHORAX

Abstract

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Chylothorax is a rare entity that is typically associated with significant morbidity and mortality. A majority of cases of chylothorax are secondary to trauma; however, a significant number of chylous effusions are due to non-traumatic causes. This case report describes a recurrent, non-surgical chylous pleural effusion in an elderly male from presumed minimal neck trauma. CASE PRESENTATION: An elderly Caucasian male with a history significant for chronic HErEF, coronary artery disease, and cirrhosis secondary to amiodarone use who presented with progressive dyspnea on exertion after sustaining blunt injury to his R shoulder. Initial chest film demonstrated a large right sided pleural effusion, which was new compared to a prior chest film obtained two weeks earlier. Pulmonary medicine was consulted to perform right sided thoracentesis. 3 liters of chylous fluid was removed. Chemistry findings of the pleural fluid were transudative based on Light's criteria; however, pleural triglyceride level was elevated at 283 mg/dL with a pleural cholesterol level less than 50 mg/dL. Flow cytometry obtained on the pleural fluid was negative for malignant cells. A bedside ultrasound was completed at the time of initial thoracentesis, which did not demonstrate any abdominal ascites. A CT chest/abdomen was obtained, which was negative for evidence of malignancy. Patient developed worsening dyspnea, which prompted repeat thoracentesis two days following his initial thoracentesis with pleural studies again consistent with chylothorax. Patient was then referred for lymphangiography to assess the thoracic duct; however, access was unsuccessful despite two attempts. The chylous effusion reaccumulated every 48 hours and required repeat large volume thoracentesis. Patient developed progressive renal failure and was ultimately transitioned to hospice care. DISCUSSION: It is thought that approximately 50% of chylothorax cases are secondary to trauma. Non-traumatic causes of chylothorax comprise about 40% cases with a majority being secondary to lymphoproliferative malignancies. Transdiaphragmatic fluid migration of chylous ascites and thoracic duct obstruction from increased portal venous pressure have also been seen in patients with underlying cirrhosis. Lymphangiography remains the gold standard for visualization of the thoracic duct; however, this is a protracted procedure with an approximate 80% success rate. There are currently no evidence based guidelines for the evaluation or management of a chylothorax. CONCLUSIONS: This case report reaffirms the notion that chylothorax continues to have a significant morbidity and mortality despite aggressive clinical evaluation. It also demonstrates that minimal trauma can potential result in a thoracic duct injury leading to recurrent chylothorax. It also highlights that there are no current evidence-based guidelines for the evaluation and management of a chylothorax. REFERENCE #1: Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respiratory Medicine. 2019;157:7-13. doi:10.1016/j.rmed.2019.08.014 REFERENCE #2: Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: An Old Technique Retains Its Usefulness. RadioGraphics. 2003;23(6):1541-1558. doi:10.1148/rg.236035704 REFERENCE #3: Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol. 2011;52(3):305-311. doi:10.1258/ar.2010.090356 DISCLOSURES: No relevant relationships by Jared Dyer, source=Web Response no disclosure submitted for Rebecca Potfay