Primary idiopathic chylopericardium associated with cervicomediastinal cystic hygroma

Clinical characteristics, evaluation and outcomes of chylopericardium: a systematic review

OBJECTIVE

Chylopericardium (CPE) is a rare condition associated with accumulation of triglyceride-rich chylous fluid in the pericardial cavity. Due to minimal information on CPE within the literature, we conducted a systematic review of all published CPE cases to understand its clinical characteristics, management and outcomes.

METHODS

We performed a literature search and identified cases of patients with CPE from 1946 until May 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We identified relevant articles for pooled analyses of clinical, diagnostic and outcome data.

RESULTS

A total of 95 articles with 98 patients were identified. Patient demographics demonstrated male predominance (55%), with a mean age of 37±15 years. Time from symptom onset to diagnosis was 5 (Q1 4.5, Q3 14) days, with 74% of patients symptomatic on presentation. Idiopathic CPE (60%) was the most common aetiology. Cardiac tamponade secondary to CPE was seen in 38% of cases. Pericardial fluid analysis was required in 94% of cases. Lymphangiography identified the leakage site in 59% of patients. Medical therapy (total parenteral nutrition, medium-chain triglycerides or octreotide) was undertaken in 63% of cases. In our cohort, 32% progressed towards surgical intervention. During a median follow-up of 180 (Q1 180, Q3 377) days, CPE recurred in 16% of cases. Of the patients with recurrence, 10% were rehospitalised.

CONCLUSION

CPE tends to develop in younger patients and may cause serious complications. Many patients fail medical therapy, thereby requiring surgical intervention. Although overall mortality is low, associated morbidities warrant close follow-up and possible reintervention and hospitalisations.

Spontaneous chylopericardium in an adult due to mediastinal cystic hygroma

Chylopericardium is a rare and benign condition. Apart from common causes like non-surgical trauma, tuberculosis, malignancy, radiation, and postoperative, mediastinal cystic hygroma presenting as chylopericardium is an extremely rare entity. Primary or idiopathic chylopericardium is diagnosed when the precise cause is not known. It is a diagnosis of exclusion. We report a 27-year-old lady with mediastinal cystic hygroma, presenting as spontaneous chylopericardium, who was managed surgically with no recurrence on 18 months follow-up. She was evaluated for complaints of discomfort in the upper abdomen region and breathing difficulty in left lateral position for 4 days, and was found to have a large pericardial effusion with impending tamponade. She underwent pericardiocentesis, and on fluid analysis, it was confirmed as chylous pericardial effusion. She was evaluated thoroughly and was taken up for right video-assisted thoracoscopy. The thoracic duct was clipped and a window was created in the pericardium, the cystic hygroma was excised, and pleurodesis was done. The postoperative period was uneventful. Histopathology of the pericardial window showed chronic inflammatory pathology and cystic lesion was confirmed as a chylous cyst.

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.

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.

Chylopericardium with symptoms of tamponade on the grounds of extensive neck vein thrombosis

Chylopericardium is a recognized complication of thoracic trauma, surgery or malignancy. Idiopathic or primary presentations, however, are rarely encountered in clinical practice. The severity of its presentation varies from the complete absence of symptoms to cardiac tamponade. We present the case of a 23-year-old woman with chylopericardium and extensive neck vein thrombosis that was managed surgically with a pericardial window.

Chylopericardium Secondary to Lymphangiomyoma - A case report -

Chylopericardium is a rare disease entity characterized by the accumulation of chylous fluid in the pericardial sac. It usually arises from mediastinal neoplasms, thrombosis of the subclavian vein, tuberculosis, nonsurgical trauma, thoracic or cardiac surgery. The spectrum of symptoms for chylopericardium varies from an incidental finding of cardiomegaly to dyspnea, upper abdominal discomfort, cough, chest pain, palpitation, fatigue. However, most of the patients are asymptomatic. The main purpose of treatment of chylopericardium is the prevention of cardiac tamponade and prevention of metabolic, nutritional, and immunological compromise due to chyle leak. Here, we report a case of chylopercardium secondary to lymphangiomyoma with review of the literature.

Bilateral chylothorax, chylopericardium and chylous ascitis

Non-Hodgkin's lymphoma (NHL) can commonly present as chylothorax and rarely as chylopericardium. Here we are presenting a case of a 21-years-old female with bilateral chylothorax, chylopericardium and chylous ascites all together finally diagnosed to have NHL as the etiology. To the best of our knowledge, it has been reported very infrequently.

Chylopericardium presenting with tamponade and cardiogenic shock

We are presenting a rare case of cardiogenic shock caused by chylopericardium. After the initial pericardial drainage and failed conservative treatment, thoracic duct ligation was performed with good long-term outcome. Literature on the subject is reviewed.

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.

A case of cardiac lymphangioma presenting as a cystic mass in the right atrium

A 44-year-old woman underwent surgery for an asymptomatic primary tumor of the heart located in the right atrium. The tumor was detected incidentally during follow-up computed tomography for a resected breast cancer. The mass, lying along the lower portion of the right atrial septum, was homogenous and cystic in nature, as detected by transthoracic and transesophageal echocardiography. Complete resection was performed via a median sternotomy under cardiopulmonary bypass. The postoperative course was uneventful. However, the histological result was surprising: the mass was a cardiac lymphangioma.

Chylopericardium presenting as cardiac tamponade secondary to an anterior mediastinal cystic teratoma

Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The many causes of tamponade include malignancy, infection, inflammation, connective tissue disorders, and uremia. Herein, we report the case of a young woman who presented with syncope. She was found to have cardiac tamponade secondary to a chylous pericardial effusion that was due to a mature and benign anterior mediastinal cystic teratoma. Numerous reports have described pericardial effusions secondary to an anterior mediastinal cystic teratoma; however, to our knowledge, this is the 1st case of a teratoma causing chylopericardium that presented as tamponade.

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.

Chylopericardial tamponade

Pericardial tamponade is a life-threatening emergency. Chyle is a rare cause of pericardial effusion and can lead to cardiac tamponade. This case illustrates the presentation, work-up and operative video of a patient in pericardial tamponade secondary to chylopericardium.