Intrapleural Infection Causing Pleurodesis in a Patient With Refractory Chylothorax Related to Yellow Nail Syndrome

Abstract

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Yellow nail syndrome (YNS) is a rare cause of chylothorax, and empyema is an unusual complication in these patients. While tunneled intrapleural catheter (IPC) related infections are uncommon, they may lead to post-infectious pleurodesis. Herein we report a case of refractory chylothorax due to YNS with empyema leading to post-infectious pleurodesis. CASE PRESENTATION: A 66 year old man with YNS, manifested by chronic chylous pleural effusions managed by placement of tunneled IPCs 4 years prior, was admitted to the hospital with increasing dyspnea and oxygen requirement. Imaging revealed patchy opacities in the bases of the lungs bilaterally, and broad antibiotic coverage was initiated. Ultrasound demonstrated increased septations within the pleural fluid compared to previous imaging, and bilateral thoracenteses were performed with Enterococcus faecalis growth noted from the left effusion. Evacuation of the pleural space was accomplished via instillation of fibrinolytic agents via the left IPC, and was later repeated on the right following decrease in output with noted increase in septations on ultrasound. Antibiotic coverage was continued for a total of three weeks. On follow-up, the catheters had both stopped draining for three weeks, and ultrasound revealed small residual effusions allowing removal of both catheters. There was no recurrence of the effusions at 6 months, demonstrating pleurodesis. DISCUSSION: Yellow nail syndrome is a rare disorder characterized by thickened and yellow nails with lymphedema and multiple respiratory manifestations. The cause is unknown, but the mechanism of the clinical manifestations is thought to be acquired lymphatic dysfunction. A recent review of the literature has identified less than 400 cases with an estimated prevalence in the general population of < 1:1,000,000. While parapneumonic effusions and empyemas are quite common complications of bacterial pneumonia, empyemas appear to be uncommon within YNS, with one study documenting empyema in only 3.5% of patients (3/85). A 2013 study of over 1000 patients with malignant pleural effusions by Fysh et al. demonstrated that IPC related infections were uncommon, occurring in <5% of cases, but of these, 62% (31/50) achieved post-infectious pleurodesis. CONCLUSIONS: Our patient required long term IPC management for chronic chylothoraces; however, following treatment for empyema, achieved bilateral pleurodesis with durable response. Though infections are undesirable, pleurodesis is a positive outcome that is commonly noted in IPC related infections. Reference #1: Fysh, E. T., et al. (2013). “Clinical outcomes of indwelling pleural catheter-related pleural infections: an international multicenter study.” Chest 144(5): 1597-1602. Reference #2: Valdes, L., et al. (2014). “Characteristics of patients with yellow nail syndrome and pleural effusion.” Respirology 19(7): 985-992. Reference #3: Vignes, S. and R. Baran (2017). “Yellow nail syndrome: a review.” Orphanet J Rare Dis 12(1): 42 DISCLOSURE: The following authors have nothing to disclose: Bryan Kelly, Ryan Kern No Product/Research Disclosure Information