Pedal (99m)Tc-sulfur colloid lymphoscintigraphy in primary isolated chylopericardium

Chylopericardium following esophagectomy: a case report and systematic review

BACKGROUND

Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition.

CASE PRESENTATION

A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy.

CONCLUSION

Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.

Review of chylopericardium

Chylopericardium is a rare pathologic condition consisting of the accumulation of excess amounts of chylous fluid within the pericardial cavity. Most patients are asymptomatic at presentation; however, chest pressure, chest pain and lightheadedness have been reported, and the most common presenting symptom is shortness of breath. Patients are noted to have enlargement of the cardiac silhouette on routine chest radiograph, and evidence of a pericardial effusion on echocardiography. The diagnosis is only definitively confirmed with pericardiocentesis and fluid analysis. The fluid is typically turbid white or milky in appearance, with a triglyceride level in excess of 500 mg/dL. The mechanism by which chyle accumulates within the pericardium is believed to be secondary to abnormal or damaged lymphatics or due to elevated pressure within the thoracic duct that results in chyle reflux into the pericardium. Following drainage with a pericardiocentesis or pericardial drain, attempts at conservative therapy with nothing by mouth and parental nutrition can be made, but have a high rate of failure and subsequent reaccumulation of chyle. Surgical treatment provides the most definitive management and consists of ligation of the thoracic duct just above the level of the diaphragm and creation of a pericardial window. With this treatment, risk of recurrence is incredibly low (<5%).

Chylopericardium Due to Residual Lymphangiomyoma Detected on 99mTc-Sulfur Colloid Lymphoscintigraphy

ABSTRACT

Lymphangiomyomas are relatively rare, benign neoplasms. Many patients present with symptoms including effusions, and some cases are incidentally detected. Surgical excision is the treatment of choice, but because of its location, complete surgical resection of a lymphangioma can be technically difficult, and recurrent cases can present with symptoms including effusions. 99mTc-sulfur colloid scan can be used to confirm the leak and nature of the effusion fluid. Here, we present an 8-year-old girl with recurrent pleural and pericardial effusions after lymphocele excision and total pericardiectomy. 99mTc-sulfur colloid lymphoscintigraphy was done to rule out secondary chylopericardium.

Chylopericardium Effusion in a Lac Alaotra Bamboo Lemur (Hapalemur alaotrensis)

Simple Summary

The clinical staff of the Veterinary Teaching Hospital of the University of Milan in Lodi have worked closely with veterinarians operating in a famous zoological park in Northern Italy. Thanks to this collaboration it has been possible to properly manage the clinical case reported in this brief communication. In veterinary medicine, clinical cases of chylopericardium in the species Hapalemur alaotrensis have never been described in the literature. Even in more common species, such as dogs and cats, it is a very rare pathology. The description of this clinical case and its diagnostic management can be a valid clinical and anatomopathological support for other colleagues who face a similar case, so that they can focus on diagnostic investigations useful for diagnosis. A new anesthesiologic protocol, allowing the optimal management of the patient throughout the clinical procedure, is also reported in detail, as well as the detailed description of the lymphoCT examination. For all these reasons the authors think that the description of this clinical case can help other colleagues in the management of infested subjects.

Abstract

An 11-year-old female Hapalemur alaotrensis was evaluated following a history of dyspnea of 15 days’ duration. Thoracic radiography performed by the referring veterinarian revealed a large cardiac silhouette and dorsal deviation of the trachea. Heart sounds were muffled. Echocardiographic findings were indicative of severe pericardial effusion without cardiac tamponade. No pleural effusion was identified. A computed tomography (CT) exam confirmed the presence of severe pericardial effusion and allowed identification of a parenchymatous mediastinal lesion sited at the level of the left hemithorax. To delineate the thoracic duct, lymphoCT was also performed by injection of iodinated contrast medium in the perianal subcutaneous tissue. Pericardiocentesis yielded a considerable amount of effusion with chylous biochemical and cytological properties. A diagnosis of chylopericardium with absence of pleural effusion was made. Initially, the chylopericardium was managed conservatively with two centesis and oral treatment with prednisolone. Medical treatment did not result in complete resolution of effusion and clinical signs; therefore, subtotal pericardiectomy and thoracic duct ligation were recommended. After the second pericardiocentesis, the subject died and the pericardiectomy could not be performed. To the authors’ knowledge, this is the first report of the development of chylopericardium in a Hapalemur alaotrensis.

Lymphoscintigraphy In a Case of Recurrent Chylopericardium

Chylopericardium is an uncommon and benign condition in which triglyceride-containing chylous fluid collects in the pericardial cavity at high concentrations. Usually, chylopericardium occurs due to congenital malformation of lymphatic vessels or secondary to any trauma, surgeries, neoplasms, etc. However, if exact aetiology cannot be identified, the condition is referred to as Idiopathic chylopericardium which is a very rare presentation in day-to-day clinical practice. General physical examination, routine blood investigations and various anatomical imaging modalities may give a clue in the diagnosis, however, diagnosis can be challenging as they have a variable presentation. Also, optimal treatment poses greater difficulty as it remains controversial in most cases. We report a 47-year-old gentleman who presented with recurrent chylous pericardial effusion with no history of trauma, thoracic surgeries, cardiac disease and neoplasm in the past. Lymphoscintigraphy confirmed the communication between the lymphatic trunk and the pericardial space. The patient was managed conservatively with pericardial drainage and the patient recovered is doing well at present.

Successful thoracic duct embolisation in a child with recurrent massive pericardial effusion diagnosed as a lymphatic anomaly

A 29-month-old girl had idiopathic massive pericardial effusion for over 6 months. Lymphangiography was performed for chronic and recurrent pericardial effusion and pulmonary lymphangiectasia, suspected based on CT findings. Magnetic resonance lymphangiography revealed chylolymphatic reflux from a tortuously dilated thoracic duct in the mediastinum to the pericardial space, suggesting primary chylopericardium with lymphangiectasia. Pericardial effusion resolved immediately after thoracic duct embolisation at the lower thoracic level. However, pericardial effusion recurred after 5 months, which resolved after additional embolisation of the abnormal lymphatic collateral vessels from the remnant upper thoracic duct. Here, we report an unusual case with chylous massive pericardial effusion diagnosed by magnetic resonance lymphangiography and treated with percutaneous embolisation.

Primary chylopericardium: A case report and literature review

Primary chylopericardium (CP) is a rare clinical condition in which chylous fluid containing high concentrations of triglyceride accumulates in the pericardial cavity. The present study reports a case of CP that was successfully treated by reconstruction surgery of thoracic duct. To improve the ability to diagnosis and treat this rare disease, the current study also systematically extracted 104 reported cases of primary or idiopathic CP from the past 60 years (January 1950 to December of 2015), and reviewed the clinical manifestation, etiology, diagnosis and treatment of these cases. The age at diagnosis varied between 6 weeks and 79 years with a mean age of 27.95±16.50 years. Asymptomatic patients accounted for 39.42% of cases, while the most common initial symptoms were dyspnea (44.23%) and coughing (10.58%). Jugular venous distention and distant heart sound was identified in 23 (22.12%) and 34 cases (32.69%), respectively. Cardiomegaly in X-ray scans was detected in the majority of patients (93.27%). In addition, lymphoscintigraphy and lymphangiography were helpful in identifying the source of chyle. Regarding the etiology, idiopathic cases accounted for 35.56% of the included cases in the present study. The most important cause of primary CP was abnormal connection or accumulation of lymph fluid in the pericardium (37.50%). Conservative therapy included low-fat or medium-chain triglyceride diet, as well as total parenteral nutrition. The majority of patients (71.2%) required surgery for definitive therapy, and thoracic duct ligation was the most preferred surgical procedure, performed in 44.23% of cases. Follow-up was reported in 64 cases, and all patients survived during the mean follow-up period of 12 months. Therefore, it is suggested that surgical management is the most successful treatment method and is associated with a favorable prognosis.

Imaging Idiopathic Chylopericardium With 99mTc-SC Lymphoscintigraphy and SPECT/CT

A 27-year-old asymptomatic active duty military man underwent a screening chest x-ray secondary to a history of tuberculosis exposure. His chest x-ray showed no features of tuberculosis infection but unexpectedly revealed a markedly enlarged cardiac silhouette. Echocardiography demonstrated a large pericardial effusion without tamponade physiology. Pericardiocentesis revealed chylous fluid. The effusion was initially refractory to drainage requiring VATS for therapy. Lymphoscintigraphy was performed using Tc-SC to evaluate lymphatic anatomy and confirm communication with the pericardial space. Novel use was made of SPECT/CT with the hope of better assessing the nature of the abnormal communication and potentially helping guide management.

Spontaneous chylous cardiac tamponade: a case report

Background

Chylous cardiac tamponade is a rare condition with little known cause.

Case presentation

A case of an otherwise healthy woman who admitted with dyspnea and palpitations is presented. She had a history of a painful flexion-hyperextension of the spine. Diagnostic evaluation proved a chylous pericardial effusion with a disruption of the anterior longitudinal spinal ligament. Video-assisted thoracic surgery with mass supradiaphragmatic ligation of the thoracic duct and pericardial window formation was carried out successfully and resulted in the complete cure of the patient's condition.

Conclusion

Chylous pericardial effusion and subsequent tamponade is a rare entity. Endoscopic surgery is offering a safe and effective treatment.

Spontaneous chylopericardium: delineation of the underlying anatomic pathology by CT lymphangiography

Primary isolated chylopericardium is a rare condition with little known cause. This is the case of a 22-year-old woman in whom idiopathic chylopericardium developed. A lymphangiogram followed by a computed tomographic scan demonstrated occlusion of the thoracic duct and multiple lymphatic collaterals abutting the pericardial sac. Thoracic duct ligation resulted in the complete cure of the patient's condition. We theorized that the development of the pathologic lymphatic ducts in close proximity to the pericardium resulted in the development of the slowly accumulating chylopericardium.

Chylopericardium in adults: a literature review over the past decade (1996-2006)

OBJECTIVES

We present a systematic overview of the literature on reported cases of chylous pericardial effusion in adults over the past 10 years, assessing clinical presentation, etiology, diagnosis, and treatment.

METHODS

We conducted an evidence-based literature review searching for all reported adult cases of chylopericardium in the past 10 years (January 1996-December 2006).

RESULTS

A total of 33 reported cases of chylopericardium were identified through a systematic literature search. There was no gender bias in the incidence of chylous pericardial effusion. Age at diagnosis varied from 18 to 68 years with a mean +/- standard deviation of 36.78 +/- 14.71 years. Time from symptom onset to diagnosis was variable (ranging from acute presentation to several years). The most common reported etiology was idiopathic. The diagnosis was made by pericardiocentesis in all patients. A search for secondary causes included computed tomography of the chest, lymphoscintigraphy, and lymphangiography along with radioactive oral (131)I-triolein. Conservative therapy was prescribed in 28 patients and failed in 16, in whom subsequent surgery was necessary. Overall, 21 patients underwent various types of surgery. Thoracic duct ligation with creation of a pericardial window was the most common surgical procedure.

CONCLUSION

Chylopericardium is a rare entity. The fluid appearance, triglyceride content, cytologic characteristics, and negative cultures are crucial to make the correct diagnosis. Treatment is dependent on the etiology. Surgical management is the most successful. Conservative therapy is reserved for patients with idiopathic chylopericardium, those with an untreatable etiology, those considered at high risk for surgical treatment, or those with a predictably short lifespan.

Idiopathic primary chylopericardium in a dog

CASE DESCRIPTION

A 7-year-old spayed female Labrador Retriever was evaluated because of pericardial effusion.

CLINICAL FINDINGS

The dog had a history of decreased appetite and exercise intolerance of 3 days' duration. Thoracic radiography performed by the referring veterinarian revealed a large cardiac silhouette. Heart sounds were muffled. Echocardiographic findings were indicative of severe pericardial effusion with cardiac tamponade; no pleural effusion was identified. Pericardiocentesis yielded a considerable amount of chylous fluid. A diagnosis of chylopericardium in the absence of pleural effusion was made.

TREATMENT AND OUTCOME

Conservative management was not effective, and subtotal pericardectomy and thoracic duct ligation were recommended. Surgery was postponed by the owners for 25 days, at which time the dog had both chylopericardium and chylothorax. The dog underwent subtotal pericardectomy and thoracic duct ligation; to delineate the thoracic duct, intraoperative lymphangiography was performed by injection of a radiopaque contrast agent directly into a mesenteric lymph node and subsequent injection of methylene blue solution into another mesenteric lymph node. Surgical treatment resulted in complete resolution of the clinical signs and pleural effusion.

CLINICAL RELEVANCE

To the authors' knowledge, this is the first report of the development of chylopericardium prior to development of chylothorax in a dog. Treatment with thoracic duct ligation and pericardectomy resulted in complete resolution of the effusion and clinical signs.