Nontraumatic Chylothorax Research Articles

A Rare Case of Membranous Nephropathy Complicated by Chylothorax.

Chylothorax can be classified into traumatic and nontraumatic based on the etiology. Nephrotic syndrome is a very rare cause of nontraumatic chylothorax in adults. A 66-year-old woman with membranous nephropathy who was non-compliant with her management, presented with dyspnea, and was found to have a large right sided chylothorax. Her chylothorax was secondary to membranous nephropathy after excluding other causes, which has been rarely reported in literature. This case highlights the possibility of nephrotic syndrome causing chylothorax, especially in patients with undiagnosed nephrotic syndrome or patients non-compliant with their management. When evaluating a patient with chylothorax, providers should consider nephrotic syndrome in the differential diagnosis. Chylothorax can be secondary to nephrotic syndrome which has been rarely reported in literature.Providers should be aware of nephrotic syndrome as a cause of chylothorax especially in patients with undiagnosed nephrotic syndrome or non-compliance with their management.Treatment of underlying cause is usually sufficient for spontaneous resolution of chylothorax with or without pleural fluid evacuation.

Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization.

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

Nontraumatic Chylothorax: A Case Series From a Safety-Net Hospital

Nontraumatic Chylothorax: A Case Series From a Safety-Net Hospital

Chylothorax Management Four Years Post Spine Surgery: A Successful Conservative Treatment

Background: Chylothorax is a pathological condition associated with a high mortality and morbidity rate. The first observation of chylothorax associated with thoracic vertebral injury was documented by Krabbell in 1885. Since then, several cases have been described in the literature.
 Non traumatic chylothorax several years after spine surgery is a rare condition. We described a case of a patient who sustained a thoracic spine fracture-dislocation and presented with a right sided chylothorax as a late complication to his thoracic spine trauma. A right thoracentesis was performed, providing partial relief of respiratory symptoms. The collected fluid was sent to the laboratory for further examination. Biochemical analysis of the milky pleural fluid confirmed the suspicion of chylothorax, with elevated levels of triglycerides and lymphocytes. These findings supported the diagnosis of chylothorax.
 Conclusion: Non-traumatic chylothorax occurring several years after spine surgery is a rare condition, and there is limited literature available on this particular pathology. The diagnosis can be simplified through laboratory examination of the milky fluid. Conservative treatment is typically the approach of choice in the majority of cases, involving total parenteral nutrition and the insertion of a chest tube into the chest cavity, followed by chemical pleurodesis.

Hodgkin\'s Lymphoma in a Milky Way

Chylothorax refers to the accumulation of chyle in the pleural space. The most common cause of nontraumatic chylothorax is tuberculosis, malignancy, and congenital causes. We share a case of bilateral chylothorax in a 24-year-old male patient admitted with complaints of fever, dry cough, and dyspnea, initially suspected of tuberculosis. The effusion was drained, and a biochemical test revealed chylothorax. Chest radiograph showed widening of mediastinum. Contrast-enhanced computed tomography done revealed lobulated anterior and superior mediastinal mass lesion possibility of lymphoma. Excision biopsy of the lymph node was done, and the biopsy report revealed histological features consistent with the malignant lymphoproliferative process in favor of the nodular sclerosis variant of classic Hodgkin's disease. This case reveals bilateral chylothorax as the first manifestation in a young male patient of Hodgkin's lymphoma. Early suspicion and systematic diagnosis provide good outcome.

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

Non-traumatic chylothorax: diagnostic and therapeutic strategies.

To review the pathophysiology, aetiology, and epidemiology of non-traumatic chylothorax.To discuss diagnostic and therapeutic strategies in the management of non-traumatic chylothorax.

Nontraumatic Chylothorax and Chylopericardium: Diagnosis and Treatment Using an Algorithmic Approach Based on Novel Lymphatic Imaging.

Rationale: Outcomes of interventional lymphangiographic treatment of nontraumatic chylous pleural effusions using traditional approaches have been highly variable. Recent advances in lymphatic imaging have revealed variations in underlying pathophysiology, enabling improved targeting of therapeutic interventions. Objectives: To assess outcomes of an algorithm for management of nontraumatic chylous pleural effusions based on advanced magnetic resonance (MR) identification of various abnormalities in the thoracoabdominal lymphatic network that give rise to chylothorax. Methods: Novel lymphatic MR imaging was performed in 52 patients aged 11-89 years. Three distinct pathophysiological patterns were found: 1) abnormal pulmonary lymphatic flow from the thoracic duct only; 2) abnormal pulmonary lymphatic flow from retroperitoneal lymphatic networks with or without involvement of the thoracic duct; and 3) chylous ascites presenting as chylous pleural effusion. Lymphatic interventions were individualized to the underlying pathophysiological patterns. Results: In 41/52 (79%) patients, imaging revealed abnormal pulmonary lymphatic flow from the thoracic duct and/or retroperitoneal lymphatic networks. Thoracic duct embolization and/or interstitial embolization of retroperitoneal lymphatic resulted in resolution of chylothorax in this group in 38/41 (93%) of those patients. Five patients experienced grade 1 or 2 complications. One patient succumbed to postoperative stress-induced cardiomyopathy and pulmonary embolism. Chylous ascites was the cause of chylothorax in 11/52 (21%) patients. Eight chose to undergo interventions for chylous ascites with clinical success in 6/8 (75%). Conclusions: Application of magnetic resonance imaging-guided intervention algorithm resulted in successful control of nontraumatic chylothorax in 93% patients with abnormal pulmonary lymphatic flow. Appropriate treatment of chylous ascites presenting as a pleural effusion requires systematic evaluation and diagnosis prior to potential treatments.

Left cervical swelling due to lymphatic intraluminal obstruction.

A 42-year-old woman had presented to the outpatient clinic because of a swelling of the left cervical region. Her medical history was remarkable for multiyear episodes of recurrent cervical swelling with abdominal pain that always regressed spontaneously. The physical examination showed a soft nontender mass in the left supraclavicular fossa without pain or skin redness (A). Magnetic resonance lymphography (B) without contrast injection showed a marked dilation of the thoracic duct (arrowhead). We also visualized a dilation of the cervical lymphatic duct network (long arrow). The terminal part of the thoracic duct showed a segmental dilation ≤13 mm with visualization of lymphatic intraluminal obstruction (LIO; short arrows). Ultrasound examination (C) focused on this area confirmed the LIO of the terminal portion of the thoracic duct. No other lymphatic or vascular malformations were demonstrated by thoracoabdominal computed tomography or magnetic resonance imaging. One week later, the patient had recovered uneventfully with complete resorption of the cervical swelling. Because the cervical swelling had spontaneously resolved, surgery was not considered.1Veziant J. Sakka L. Galvaing G. Tardy M.M. Cassagnes L. Filaire M. Lymphovenous anastomosis for recurrent swelling syndrome and chylous effusion due to cervical thoracic duct cyst.J Vasc Surg. 2015; 62: 1068-1070Google Scholar A supraclavicular mass can arise from infectious disease, a branchial clef cyst, or a benign or malignant tumor. LIO of the thoracic duct is a rare condition that can cause recurrent swelling of the cervical region.2Kunze G. Staritz M. Lymph vessel thrombus detection in cervical lymphedema: a case series.J Ultrasound Med. 2017; 36: 1955-1960Google Scholar Magnetic resonance lymphography without contrast media injection allows for easy visualization of the lymphatic duct network and can directly demonstrate the LIO without the need to inject contrast media.3Cholet C. Delalandre C. Monnier-Cholley L. Le Pimpec-Barthes F. El Mouhadi S. Arrivé L. Nontraumatic chylothorax: nonenhanced MR lymphography.Radiographics. 2020; 40: 1554-1573Google Scholar,4Arrivé L. Derhy S. El Mouhadi S. Monnier-Cholley L. Menu Y. Becker C. Noncontrast magnetic resonance lymphography.J Reconstr Microsurg. 2016; 32: 80-86Google Scholar The patient gave her written informed consent for the report of her case details and imaging studies.

REFRACTORY CHYLOTHORAX SECONDARY TO WALDENSTROM MACROGLOBULINEMIA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: A chylothorax is defined by the presence of chyle within the pleural cavity. Chylothoraces can be observed as a complication of malignancy; however, Waldenstrom Macroglobulinemia (WM) has rarely been described as a potential cause. We present a case of a refractory chylothorax secondary to WM presenting as a periaortic mass, which eventually required thoracic duct embolization (TDE). CASE PRESENTATION: A 76-year-old male former heavy smoker underwent a low-dose chest CT that showed a large right-sided pleural effusion with suggestion of subcarinal lymphadenopathy. The patient underwent a right-sided thoracentesis, and pleural fluid appeared milky-orange (Figure 1) with triglyceride concentration of 410 mg/dL, diagnostic of a chylothorax. Contrast chest CT revealed a soft tissue mass encasing the descending aorta (Figure 2). Tissue sampling via endobronchial ultrasound (EBUS) demonstrated a monomorphic population of small lymphocytes expressing CD19, CD20, and CD22, while being negative for CD5 and CD10. Additional oncological evaluation including the detection of a MYD88 L265P mutation led to a diagnosis of WM. The patient was started on combination chemoimmunotherapy and had notable tumor response; however, he continued to require high-volume therapeutic thoracentesis (2.5 liters per week). The patient was referred to interventional radiology and underwent successful TDE without complications. Within weeks of thoracic duct embolization, the patient's milky pleural effusion decreased significantly in amount and transitioned to a serosanguinous appearance with a triglyceride concentration of 60 mg/dL. The patient had significant dyspnea relief with decreased frequency of thoracentesis leading to an improved quality-of-life. DISCUSSION: Lymphoma is the most common malignancy-associated cause of a chylothorax. WM is rarely described as a cause in the literature, especially in the setting of a periaortic mass. Malignancy-associated chylothoraces commonly improve with chemotherapy; however, this patient continued to require therapeutic thoracentesis after months of effective chemotherapy. Pedal lymphangiography identified a lymphatic leak within the chest, and TDE was successfully performed without complications. CONCLUSIONS: In patients with a non-traumatic chylothorax, malignancy should be high on the differential diagnosis. Refractory chylothorax can cause serious decrement in quality-of-life due to chronic dyspnea, malnutrition, and recurrent pleural procedures. Early referral for TDE should be considered by chest physicians in patients with refractory chylothorax. REFERENCE #1: Rudrappa M, Paul M. Chylothorax. In: StatPearls. Treasure Island: StatPearls Publishing; 2021 Jan. REFERENCE #2: Otoupalova E, Meka SG, Dogra S, Dalal B. Recurrent chylothorax: a clinical mystery. BMJ Case Rep. 2017;2017:bcr2017220750. Published 2017 Oct 6. doi:10.1136/bcr-2017-220750 DISCLOSURES: No relevant relationships by Ali Bukhari, source=Web Response No relevant relationships by Matthew Koroscil, source=Web Response No relevant relationships by Nathan Mullen, source=Web Response

Abnormal Pulmonary Lymphatic Flow on Novel Lymphangiographic Imaging Supports a Common Etiology of Lymphatic Plastic Bronchitis and Nontraumatic Chylothorax.

Background: This study evaluates whether dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) and thoracic duct lymphangiography (TDL) findings in adults with lymphatic plastic bronchitis (PB) and/or nontraumatic chylothorax (NTC) support a shared pathophysiology. Materials and Results: Retrospective review of clinical and imaging findings in patients who underwent DCMRL and TDL at a single institution from March 2017 to March 2019. Categorical variables were compared with Fisher's exact test. Twenty-eight patients (median age 61 ± 21 years, 15 women) presenting with lymphatic PB (n = 13), NTC (n = 10), or both (n = 5) were included. Lymphatic imaging demonstrated pulmonary lymphatic perfusion (PLP) in all patients. A patent thoracic duct (TD) with retrograde flow was seen in 53.4% (7/13) of patients with PB, 60% (6/10) of patients with NTC, and 20% (1/5) of patients with both (p = 0.69). An occluded TD with retrograde flow was seen in 30.8% (4/13) of patients with PB, 30% (3/10) of patients with NTC, and 80% (4/5) of patients with both (p = 0.12). Similar patterns of PLP between DCMRL and TDL were seen in 96.2% (25/26) of patients. Conclusions: DCMRL and TDL demonstrated similar findings in patients with lymphatic PB and/or NTC, supporting a common etiology. This supports the hypothesis that the clinical presentation depends on the proximity of abnormal lymphatic vessels to the pleural cavity, resulting in chylothorax, or bronchial mucosa, resulting in PB.

Nontraumatic Chylothorax: Nonenhanced MR Lymphography.

Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Because the lymphatic system plays an essential role in fat absorption and immune response, lymphatic leak associated with chylothorax may cause life-threatening malnutrition and immunodeficiency. Chylothorax is usually described as traumatic or nontraumatic. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Lymphoma and thoracic malignancies are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. Other rare causes include primary and secondary diffuse lymphatic diseases, responsible for chylothorax by lymphatic vessel wall dysfunction. Imaging the lymphatic system remains a challenge in the days of modern imaging. Nonenhanced MR lymphography is a noninvasive technique based on heavily T2-weighted sequences, thus enabling visualization of the lymphatic circulation. This technique allows diagnosis and differential diagnosis, evaluation of disease severity, and guidance of therapeutic management in nontraumatic chylothorax. Furthermore, it may offer radiologic classification of primary lymphatic diseases on the basis of morphologic features of lymphatic vessels. The authors describe the anatomy and physiology of the thoracic lymphatic system, present the technique of nonenhanced MR lymphography, and discuss pathophysiologic mechanisms and imaging features in different causes of nontraumatic chylothorax. ©RSNA, 2020.

A Case of the Successful Use of Lipiodol Lymphangiography and Octreotide in Non-traumatic Chylothorax

A Case of the Successful Use of Lipiodol Lymphangiography and Octreotide in Non-traumatic Chylothorax

Respiratory syncytial ウイルス細気管支炎に合併した乳び胸の一例

Chylothorax is a condition in which chyle leaks into the thoracic cavity. The causes of chylothorax can be nontraumatic, traumatic or idiopathic. The most common cause of nontraumatic chylothorax is obstruction of the thoracic duct by tumor. Traumatic chylothorax is caused by disruption of the thoracic duct, most often due to cardiac surgery or a thoracic surgical procedure, although in rare cases by cough or vomiting. We report the case of a 3-month-old boy with respiratory syncytial (RS) virus infection who presented with right chylothorax. No obstructive tumor mass was identified in the thoracic duct. Clinical symptoms of Noonan syndrome and Down syndrome, which often accompany lymphatic anomaly, were not found. Therefore, we speculate that his severe cough caused a high thoracic pressure and a disruption of the thoracic duct. He was treated by thoracocentesis and MCT milk. One month later, pleural effusion disappeared and did not recur. RS virus infection might be a rare cause of chylothorax in infants.

An Algorithmic Approach to Minimally Invasive Management of Nontraumatic Chylothorax.

Chylothorax is a rare condition characterized by lymph accumulation in the pleural space. When it occurs independent of trauma, it is even more rare and difficult to treat as identification of lymphatic leak is unpredictable. In addition, treatment of this condition with conventional lymphangiography and thoracic duct embolization may not result in positive outcomes. As such, the role of contrast-enhanced dynamic magnetic resonance lymphangiography to guide treatment is key to maximizing success with the advantage of localizing the site of lymphatic leak. Herein, we summarize etiologies of nontraumatic chylothorax, offer an updated treatment algorithm to stratify affected patients and determine appropriate treatment options, and review procedural techniques critical to efficient and effective treatment.

Bilateral chylous effusions as a complication of advanced chronic lymphocytic leukemia

Introduction: A chylous effusion, or chylothorax, is a collection of milky fluid consisting of emulsified fats that has accumulated in the pleural space due to extravasation from lymphatic vessels, mainly the thoracic duct. There are three main etiologies of chylothorax—traumatic, non-traumatic, and idiopathic. Non-traumatic chylothorax is typically associated with malignancy, though an association with chronic lymphocytic leukemia (CLL) is very rarely seen or reported.

BILATERAL CHYLOTHORAX SECONDARY TO SPONTANEOUS THORACIC DUCT ANEURYSM

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Chylothorax is a rare cause of pleural effusion despite a normal thoracic duct draining 1-2 liters of fluid per day. Diagnosis is made by confirming the presence of chylomicrons in pleural fluid and defined by pleural fluid triglyceride levels >1.24 mmol/l (110 mg/dl) with a cholesterol CASE PRESENTATION: A 61 year old male without past medical history was admitted for 2 days of dyspnea and bilateral large pleural effusions. Diagnostic right thoracentesis was exudative, milky, with markedly elevated triglyceride level (3,315 mg/dL) and low cholesterol level (<50 mg/dL) consistent with chylothorax. Thoracentesis of the left was transudative but also consistent with chylothorax (triglyceride of 3,585 mg/dL; cholesterol <50 mg/dL). Therapeutic thoracenteses involved 3L removed from the right pleural space on day 1, 1.5L from the left side on day 2. Subsequent draining of 0.8L from the right on day 5. All samples were consistent with chylothorax. Extensive medical and surgical histories were negative for any traumatic, surgical, or iatrogenic etiologies. Computerized tomography of the chest, abdomen, and pelvis was negative for malignant etiology. Given rapid recurrence and severity of symptoms, the patient underwent lymphangiography identifying a thoracic duct aneurysm at the T10-T11 level measuring 12mm with evidence of chyle leak into the left pleural space. There was no identified leak into the right pleural space. The rapid reaccumulation and symptom severity drove a decision to occlude the leaky aneurysm with multiple microcoils and n-Butyl cyanoacrylate with complete resolution of pleural effusions and symptoms. DISCUSSION: Only a few cases of idiopathic thoracic duct aneurysm resulting in chylothorax have been reported. Consideration for this etiology should be given when standard evaluation remains negative. Lymphangiography remains a useful clinical tool in diagnostic evaluation of patients with idiopathic and recurrent symptomatic chylothorax. Thoracic duct embolization has been shown to successfully cure recurrent chylothorax in 60-90% of patients. It is theorized that dormant venous anastomoses take up the lymphatic drainage following thoracic duct embolization. CONCLUSIONS: Thoracic duct aneurysm is an uncommon cause of non-traumatic chylothorax. Lymphangiography remains an option for diagnosis and intervention for idiopathic chylothorax. Reference #1: Eric Chen, M.D.1 and Maxim Itkin, M.D.. Thoracic Duct Embolization for Chylous Leaks. Semin Intervent Radiol. 2011 Mar; 28(1): 63–74. Reference #2: Gomes AO, Ribeiro S, Neves J and Mendonça T. Uncommon aetiologies of chylothorax: superior vena cava syndrome and thoracic aortic aneurysm. Clin Respir J 2015; 9: 185–188. DISCLOSURES: No relevant relationships by Jack Buckley, source=Web Response No relevant relationships by Nichole Smith, source=Web Response

Concurrent Occurrence of Chylothorax and Chyloperitoneum in Non-Hodgkin’s Lymphoma

Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. Chylothorax is classified as non-traumatic or traumatic. Non-traumatic chylothorax is mainly caused by malignant etiologies accounting for more than 50% of chylothorax diagnoses. Lymphoma is the most common etiology. Chyloperitoneum is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity, which can occur as a result of trauma or obstruction of the lymphatic system. Chylous ascites is an uncommon finding that can be caused by malignancy, cirrhosis and lymphatic disruption after abdominal surgery. The combination of chyloperitoneum and chylothorax is rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. The Patient is an 82 year old Caucasian male who presented with worsening shortness of breath and abdominal distension. Chest X-ray showed moderate left sided pleural effusion. Bedside ultrasound-guided paracentesis and thoracentesis revealed milky ascetic and pleural fluid respectively. Triglyceride level was 271 mg/dl in the ascetic fluid, and 221 mg/dl in the pleural fluid. Pleural fluid was exudative with lymphocytic predominant cell count and negative cytology. Lymph node biopsy confirmed Non-Hodgkin’s Lymphoma causing the concurrent chylothorax and chyloperitoneum.

Clinical characteristics of nontraumatic chylothorax in pediatric patients

Purpose: To evaluate clinical characteristics of pediatric nontraumaitc chylothorax and to suggest appropriate therapeutic manage ments. Methods: We retrospectively reviewed medical records of 22 patients with nontraumatic chylothorax from January 2005 to Decem ber 2018 in the Children’s Hospital of Seoul National University. We analyze their etiology, treatment, complications and outcome. Results: Of the 22 patients, 16 were diagnosed before 1 year old and 6 after 1 year old. The causes of chylothorax under 1-year-old children were related to congenital factors (n=9), unknown causes (n=5), and high central venous pressure (n=2). The causes of chylothorax over 1-year-old children were related to congenital factors (n=3), unknown causes (n=1), high venous pressure (n=1), and lymphoma (n=1). All patients had dietary modification. Eight of them were cured by dietary modification, but there was no im provement in over 1-year-old children. Medication was added to patients refractory to dietary modification. Four patients with medication were improved and 5 were improved by surgical management. Nutritional, immunological and other complications oc curred in many patients. Five death cases were reported. Four patients were under 1 year old and 1 was over 1 year old. The causes of nontraumatic chylothorax in dead patients were high central venous pressure (n=3), congenital (n=1), and unknown (n=1). Conclusion: Nontraumatic chylothorax more frequently occurs in under 1-year-old children. The most common cause is congenital factors. Stepwise management is effective in many patients, but specific treatment is needed in some cases. The prognosis is related to the onset of age and underlying diseases. (Allergy Asthma Respir Dis 2019;7:206-211)

CHYLOUS HEPATOHYDROTHORAX: A RARE CASE MANAGED USING A MULTIMODAL APPROACH

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Chylothorax is a rare etiology of pleural effusion related to disruption of lymphatic drainage in thoracic duct or its tributaries. Chylous ascites is an even more rare finding associated with disruption of the abdominal lymphatic drainage usually associated with surgery, trauma, malignancy, and rarely cirrhosis. Chylothorax as a result of hepatohydrothorax physiology is an even less common finding (1). We present a case of a chylous hepatohydrothorax where we combined multiple treatment modalities to eliminate the pleural effusion. CASE PRESENTATION: A 60 year old female with a history of chronic hepatitis C and portopulmonary hypertension (PASP=75 mm Hg) presented with acute dyspnea and hypoxemia. Her chest X-ray demonstrated a large right pleural effusion (Figure 1). An urgent thoracentesis was performed with significant relief of symptoms; laboratory studies demonstrated a transudative chylous effusion (pleural protein = 2.1 g/dL, LDH = 44 U/L, and triglycerides (TG) = 486 mg/dL). A subsequent paracentesis confirmed concurrent chylous ascites (ascetic TG = 285 mg/dL). The subsequent day (hospital day 2), with rapid reaccumulation of the fluid, the patient developed increased respiratory distress and a chest tube was placed demonstrating the chylous hepatohydrothorax (Figure 2). The fluid was completely drained and the patient was kept NPO. Repeat fluid analysis at hospital day 5 revealed triglyceride level of 87 mg/dL; by day 10 the level had further decreased to 48 mg/dL. Low fat enteral nutrition was restarted, a Tenckhoff catheter was placed in the peritoneal space to control the ascites, and the chest tube output ceased with the tube removed on hospital day 10. Subsequent chest X-ray 1 week later showed no reaccumulation of the pleural fluid (Figure 3). She remained pleural effusion free for 3 months. DISCUSSION: Chylous ascites and chylothorax are both rare entities that can be difficult to manage (2). In this case, the etiology was postulated to be a hepatohydrothorax with migration of the fluid across the diaphragm. The mainstay for the treatment of nontraumatic chylothorax is drainage and dietary modifications. For chylous ascites, the main treatment is management of the liver cirrhosis (some studies demonstrating success after a transjugular intrahepatic portosystemic shunt procedure); dietary modification often being less successful (3). In this case, we demonstrated a very rapid resolution of triglyceride content after NPO status and were able to start low fat feeds without reaccumulation of chylous fluid; this finding demonstrated an apparent overlap in treatment options between chylothorax secondary to lymphatic drainage interruption and chylothorax secondary to cirrhotic processes. CONCLUSIONS: In all, chylous hepatohydrothorax is a rare entity that is difficult to manage; in this case, we combined the management modalities to control this patient's disease. Reference #1: Romero et al. Chylothorax in Cirrhosis of the Liver. CHEST 1998, 114: 154-159. Reference #2: Said et al. Chylous Ascites: Evaluation and Management. ISRN Hepatology, vol. 2014, Article ID 240473, 10 pages. Reference #3: de Vries et al. Cirrhosis related chylous ascites successfully treated with TIPS. Eur J Gastroenterol Hepatol, 2005;17(4):463. DISCLOSURES: No relevant relationships by Afshan Ahmed, source=Web Response No relevant relationships by Michael Bernstein, source=Web Response No relevant relationships by Lovin Pappy, source=Web Response