Recurrent Idiopathic Chylothorax: A Therapeutic Challenge

Document Type

Conference Proceeding

Publication Date

5-21-2023

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction: Chylothorax results from disruption of chyle in the thoracic duct or its lymphatic divisions resulting in its leakage into the pleural space. The etiology of chylothorax is broadly divided into traumatic and non-traumatic. Non-traumatic causes are malignancy (majorly lymphomas) and autoimmune disorders. Traumatic causes include direct injury from penetrating trauma or iatrogenic. Those cases with no apparent cause after extensive evaluation are labeled idiopathic. Case Description: A 70-year-old lady presented to the hospital with a four-week history of shortness of breath. On examination, she had normal vital signs and lower extremity non-pitting edema suggesting lymphedema. The patient was noted to have a large right-sided pleural effusion on chest-x-ray. She underwent thoracentesis showing milky appearance and elevated triglycerides in the pleural fluid suggesting chylothorax. The patient did not have any prior history of chest trauma or cardiothoracic surgeries. Laboratory testing including flow cytometry, PET-CT (Positron Emission Tomography-Computed Tomography), and pleural fluid cytology did not show any evidence of malignancy. Pleural fluid gram stain/culture and acid-fast bacilli were negative. After the therapeutic thoracentesis, the patient had a recurrence of pleural effusions requiring three more thoracenteses in the next four months. Lymphangiography was performed with thoracic duct catheterization and embolization with coils and glue. Around 6 months later, she had another chylothorax requiring thoracentesis. Robotic video thoracoscopy was done which showed chyle in the pleural space and small channels of lymphatics that appeared to be filled with chylous material (Figure) which were ligated. Despite this intervention, the patient continued to have chronic chylothorax and required one more therapeutic thoracentesis. In case the patient has more frequent symptomatic effusions, further options such as talc pleurodesis or pleuroperitoneal shunts may be considered. Discussion: Idiopathic chylothorax continues to be a therapeutic challenge due to the high recurrence rate after therapeutic thoracentesis and no treatment of etiology associated with it. First-line management of chylothorax is conservative with multiple thoracenteses as thoracic duct leak closes spontaneously in nearly half of the patients. Medical measures to reduce chyle production are TPN (Total Parenteral Nutrition) and octreotide. In previously reported cases, chylothorax completely resolved after ligation of the thoracic duct and lymphatic channels. In this case, the frequency of pleural effusions reduced considerably after surgical ligation of lymphatic channels with other therapeutic options in the armamentarium in case of more recurrences. (Figure Presented).

Volume

207

Issue

1

First Page

A3363

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