SPILLED MILK: BUFFALO CHEST WITH BILATERAL CHYLOTHORAX

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The term "buffalo chest" is used to define a single pleural space with no anatomic separation of the two hemithoraces, seen in an American buffalo or bison. There have been less than ten cases reported where spontaneous bilateral pneumothorax was suspected due to interpleural communication. The interpleural connection reported have been associated with major invasive thoracic procedures such as esophagectomy, cardiothoracic surgery, pacemaker and central venous catheter placements. We present a rare case of simultaneous bilateral chylothorax fashioned by such an interpleural communication. CASE PRESENTATION: A 45-year-old male chronic smoker with past medical history of esophagitis presented with one week of cough and reflux. He otherwise denied fevers, odynophagia, chest pain, weight loss or early satiety. He was hypoxic on admission requiring 2 L oxygen supplementation. Physical exam revealed decreased breath sounds in the left lower lung base. Chest radiograph showed minimal atelectasis at the left lung base. CT Chest showed a large sliding hiatal hernia with distention of esophagus and centrilobular nodules in the right middle lobe and bilateral lower lobes. The presumptive diagnosis was aspiration pneumonia likely secondary to hiatal hernia. Thus, he underwent laparoscopic para-esophageal hernia repair with EGD. Two days later, he developed acute hypoxic respiratory failure and was intubated. Chest radiograph was concerning for new large bilateral pleural effusions. Within hours, he underwent an ultrasound guided right thoracentesis draining four liters of opaque, pink, non-purulent fluid (figure 1). Left thoracentesis drained only five mL. Pleural fluid revealed pH 7.48, elevated triglycerides (600 mg/dL) and low cholesterol (50 mg/dL) indicating chylothorax. He had bilateral chest tubes placed and was on placed on bowel rest. Decision was made to evaluate for thoracic duct injury in the setting of recent hiatal hernia repair and he was taken for right video-assisted thoracoscopic surgery with thoracic duct ligation and talc pleurodesis. It was seen that there was a communication from the pleural cavity into the mediastinal area from the hiatal hernia dissection. This interpleural communication explained the resolution of the bilateral chylothorax with a single right-sided thoracentesis. Patient was extubated thereafter and was discharged. DISCUSSION: This report documents a rare case of bilateral chylothorax completely resolved with a single sided thoracentesis. The phenomenon was explained by the interpleural connection formed during hiatal hernia repair suggesting buffalo chest. CONCLUSIONS: Recognition of buffalo chest syndrome as a life-threatening complication is important in the setting of iatrogenic injuries during mediastinal surgeries. Prompt resolution can be achieved with a single sided thoracentesis. REFERENCE #1: Eguchi T, Hamanaka K, Kobayashi N, et al. Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication. Ann Thorac Surg 2011;92:1124-6 Hartin DJ, Kendall R, Boyle AA, et al. Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication. Emerg Med J 2006;23:483-6 REFERENCE #2: Männer J, Jakob C, Steding G, et al. Horseshoe lung: report on a new variant—"inverted" horseshoe lung--with embryological reflections on the formal pathogenesis of horseshoe lungs. Ann Anat 2001;183:261-5 REFERENCE #3: Rali AS, Manyam H. Bilateral Pneumothoraces Following BiV ICD Placement: A Case of Buffalo Chest Syndrome. Am J Case Rep. 2015;16:703–6. DISCLOSURES: No relevant relationships by Jaclyn Boozalis, source=Web Response No relevant relationships by Kevin Ferriter, source=Web Response No relevant relationships by Paul Harford, source=Web Response No relevant relationships by Kanza Muzaffar, source=Web Response No relevant relationships by Nisha Soneji, source=Admin input