Pleural fluid characteristics of chylothorax

Chylothorax in Infants and Children After Congenital Heart Surgery: Approach and Review

Chylothorax in infants after surgery for congenital heart disease is associated with significant morbidity and mortality. Numerous management modalities applied alone or in various combinations have been utilized but definitive guidelines have not yet been established. We present two infants who developed refractory chylothorax after congenital heart surgery. We also reviewed evidence for the use of available treatment modalities. In our experience, the use of lymphangiography followed by pleurodesis by povidone-iodine was safe and our impression was that it may have played a decisive role in controlling the lymph leak.

Drug-induced chylothorax as a rare pleural complication in dasatinib therapy for chronic myeloid leukaemia

Chylothorax is a lymphatic chylous pleural effusion typically associated with traumatic (iatrogenic, non-iatrogenic) and non-traumatic (infections, malignancy, lymphatic disorders) aetiologies. Drug-induced chylothorax is uncommon and mostly reported in association with BCR-ABL tyrosine kinase inhibitor therapy.

Chylothorax: pathophysiology, diagnosis, and management-a comprehensive review

Chylothorax is a rare condition characterized by the accumulation of chyle in the pleural space. While it accounts for a small percentage of pleural effusions, chylothorax can lead to significant morbidity and mortality. This article provides a comprehensive overview of chylothorax, covering its relevant anatomy, aetiology, pathophysiology, clinical features, diagnosis, and management. Injury or disruption to the thoracic duct (which is responsible for chyle transport) leads to the development of chylothorax. This may result from trauma, such as iatrogenic injury during surgery, or non-traumatic causes, including malignancy, lymphatic disorders, and heart failure. Recognition of the underlying cause is essential to tailor management. Clinical presentation varies, with symptoms linked to rate of chyle accumulation and the causative condition. Diagnosis relies on pleural fluid analysis, with demonstration of elevated triglyceride levels (>110 mg/dL) and reduced cholesterol levels (<200 mg/dL) being the key diagnostic criteria employed in clinical practice. Various imaging modalities, including computed tomography (CT) scans and lymphatic-specific investigations, may be utilised to aid identification of the site of chyle leak, as well as determine the likely underlying cause. Chylothorax management is multifaceted, with conservative approaches such as dietary modification and pharmacological interventions often initiated as first-line treatment. Drainage of chylous effusion may be necessary for symptom relief. When conservative methods fail, interventional procedures like thoracic duct ligation or embolization can be considered. Due to the diverse aetiological factors and patient characteristics associated with chylothorax, individualized management strategies are recommended. Nonetheless, management of chylothorax is an evolving field with a paucity of high-quality evidence or standardized guidelines, highlighting the importance of ongoing research and a multidisciplinary approach to optimize individual patient care.

Traumatic chylothorax in urbanized free-ranging black-tufted marmosets (Callithrix penicillata)

After fatal traumatic injuries, three urbanized free-ranging marmosets developed a milky white or pink-white thoracic alkaline effusion with high specific gravity, triglyceride levels, and predominance of small lymphocytes. Chylothorax is an uncommon thoracic fluid accumulation in animals and humans and has not been reported in free-ranging non-human primates.

Post-traumatic pleural effusion: Don't forget the chylothorax!

In this case we describe a 58-year-old male with bilateral pleural effusion after a blunt trauma to the back. A pleural puncture revealed a chylothorax. An additional computed tomography scan showed a vertebral fracture at level D8 with rupture of the nearby thoracic duct. Our patient could be treated with a conservative approach. This case highlights the importance of ruling out a chylothorax in any post-traumatic pleural effusion. Despite the low prevalence, we consider it a don't-miss diagnosis given the specific treatment requirements.

Coil or Plug-Assisted Ethylene Vinyl Alcohol Copolymer (EVOH) Thoracic Duct Embolization in the Treatment of Postoperative Chylothorax

Eleven patients (5 men, 6 women) with post-operative thoracic duct injuries and high output chylothorax were treated with thoracic duct embolization (TDE). Six patients underwent intraprocedural thoracic duct ligation at the time of original procedure. In all cases, the pleural fluid demonstrated high triglyceride levels (414 mg/dL; interquartile range [IQR], 345 mg/dL). Median daily (IQR) chest tube outputs before and after TDE were 900 mL (1,200 mL) and 325 mL (630 mL), respectively. Coil- or plug-assisted ethylene vinyl alcohol (EVOH) copolymer was used as embolic agent in all patients. Technical and clinical success rates were 100% and 82%, respectively. Nontarget venous embolization of EVOH copolymer was not identified on subsequent imaging.

Recurrent bilateral idiopathic chylothorax: a therapeutic challenge

Chylothorax is a rare condition caused by pleural effusion resulting from thoracic duct injury. Recurrent chylothorax is often resistant to conservative treatment and presents a clinical conundrum in its management. Here, we report a compelling case of recurrent chylothorax that persisted despite the administration of total parenteral nutrition, octreotide and thoracic duct embolisation. The patient eventually required thoracic duct ligation and talc pleurodesis, which resulted in the resolution of the effusion. Our case is an illustrative example of the effective multidisciplinary management of recurrent bilateral idiopathic chylothorax.

The tuberculous pleural effusion

Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease.

Educational aims

To demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.

Late-Onset Chylothorax After Coronary Artery Bypass Grafting

Chylothorax, the presence of lymph in the pleural cavity, is a significant post-cardiac surgery complication. Historically linked to left internal mammary artery (LIMA) harvesting, its occurrence in cases without LIMA usage is uncommon. This paper details a case of chylothorax in an 84-year-old female patient who underwent coronary artery bypass grafting (CABG) without LIMA harvesting. Three months post-surgery, she manifested symptoms of exertional shortness of breath and diminished breath sounds on the left side. Diagnostic measures, including echocardiography and chest X-rays, revealed a pronounced left-sided pleural effusion. Diagnostic thoracocentesis yielded a milky fluid, and laboratory analysis confirmed its chylous nature. Therapeutic interventions comprised chest tube insertion, drainage of the milky fluid, dietary modifications, and the performance of talc pleurodesis after a fatty food-provocation test resulted in increased fluid collection. The patient's journey highlights the challenges of diagnosing and managing post-cardiosurgical chylothorax. The paper emphasizes the importance of early detection and appropriate interventions to prevent complications associated with a heightened mortality risk.

Clinical characteristics of chylothorax: results from the International Collaborative Effusion database

Background

Chylothorax is an uncommon medical condition for which limited data are available regarding the contemporary aetiology, management and outcomes. The goal of this study was to better define these poorly characterised features.

Methods

The medical records of adult patients diagnosed with chylothorax at 12 centres across Europe, America and South Africa from 2009-2021 were retrospectively reviewed. Descriptive and inferential statistics were performed.

Results

77 patients (median age 69 years, male to female ratio 1.5) were included. Subacute dyspnoea was the most typical presenting symptom (66%). The commonest cause of chylothorax was malignancy (68.8%), with lymphoma accounting for 62% of these cases. Other aetiologies were trauma (13%), inflammatory/miscellaneous conditions (11.7%) and idiopathic cases (6.5%). At the initial thoracentesis, the pleural fluid appeared milky in 73%, was exudative in 89% and exhibited triglyceride concentrations >100 mg·dL-1 in 88%. Lymphangiography/lymphoscintigraphy were rarely ordered (3%), and demonstration of chylomicrons in pleural fluid was never ascertained. 67% of patients required interventional pleural procedures. Dietary measures were infrequently followed (36%). No patient underwent thoracic duct ligation or embolisation. Morbidity included infections (18%), and thrombosis in malignant aetiologies (16%). The 1-year mortality was 47%. Pleural fluid protein >3.5 mg·dL-1 (sub-distribution hazard ratio (SHR) 4.346) or lactate dehydrogenase <500 U·L-1 (SHR 10.21) increased the likelihood of effusion resolution. Pleural fluid protein ≤3.5 mg·dL-1 (HR 4.047), bilateral effusions (HR 2.749) and a history of respiratory disease (HR 2.428) negatively influenced survival.

Conclusion

Chylothoraces have a poor prognosis and most require pleural interventions. Despite the standard recommendations, lymphatic imaging is seldom used, nor are dietary restrictions followed.

A case report on chylothorax post penetrating chest trauma

INTRODUCTION AND IMPORTANCE

Chylothorax is a rare condition secondary to a chyle leak from the thoracic duct. The most common cause is after thoracic and cardiac surgery. Other causes include malignancy, non-iatrogenic trauma, and miscellaneous disorder - tuberculosis, filariasis and idiopathic conditions. The incidence of chylothorax post non-iatrogenic trauma is low; however, it does occur. Therefore, clinicians managing trauma patients should be aware of chylothorax as a differential and understand how it can be managed.

PRESENTATION OF CASE

Our patient presented in respiratory distress 5 days after sustaining a stab to the chest. His chest X-ray showed a massive left pleural effusion with mediastinal shift. An Intercostal drain (ICD) was inserted and, drained 2 l of a white milky fluid - confirmed to be chyle on biochemistry. Other potential differentials like empyema and a pseudochylothorax, were excluded. He was kept nil-per os, received total parenteral nutrition and the ICD output was monitored. Subsequently the drainage decreased and eventually cleared, and the ICD was removed on day 8 of admission. Chest X-rays showed resolution of the effusion, and the patient was discharged.

DISCUSSION

Patients with trauma can present with chylothorax after penetrating or blunt trauma. The diagnosis can be made by checking the fluid triglyceride level or the presence of chylomicrons. Once the diagnosis is confirmed, the clinician should decide on either conservative or surgical. Due to the condition's rarity, there are no randomized control trials comparing different treatment modalities.

CONCLUSION

Despite the patient's delayed presentation, he was successfully managed conservatively.

Lymphoscintigraphy findings in patients with chylothorax: influence of biochemical parameters

BACKGROUND

Chylothorax is a condition that can be challenging to diagnose due to its nonspecific clinical presentation. Several biochemical parameters of chylous pleural effusion have been identified as important indicators for the diagnosis of chylothorax. Lymphoscintigraphy is utilized to assess chylothorax and determine the location of chyle leakage. The present study aimed to evaluate the correlation between the biochemical parameters of chylous pleural effusion and 99mTc-dextran (99mTc-DX) lymphoscintigraphy in diagnosing chylothorax.

MATERIAL AND METHODS

A total of 120 patients were enrolled in the study, 83 of the patients with unilateral chylothorax, and 37 with bilateral chylothorax. All patients underwent both 99mTc-DX lymphoscintigraphy and pleural effusion laboratory analysis. The 99mTc-DX lymphoscintigraphy images were categorized as positive or negative groups based on the presence or absence of abnormal radioactive tracer accumulation in the thorax, respectively. The biochemical parameters of the two groups were subsequently compared.

RESULTS

Among these patients, 101 (84.17%) had exudative effusions, while 19 (15.83%) had transudative effusions, as determined by the levels of pleural effusion protein, lactate dehydrogenase and cholesterol. Abnormal tracer accumulation in thorax was observed in 82 patients (68.33%). Our findings indicated that lymphoscintigraphy results were not associated with exudative and transudative chylothorax (P = 0.597). The lymphoscintigraphy positive group displayed significantly higher levels of pleural effusion triglyceride and pleural effusion triglyceride/serum triglyceride ratio in all biochemical parameters, compared to the negative group (P = 0.000 and P = 0.005). We identified cutoff values of 2.870 mmol/L for pleural effusion triglycerides and 4.625 for pleural effusion triglyceride/serum triglyceride ratio, respectively, which can facilitate differentiating the positive and negative cases on lymphoscintigraphy.

CONCLUSION

Lymphoscintigraphy technique is a dependable diagnostic tool for the qualitative assessment of chylous pleural effusion. Higher pleural effusion triglyceride level and pleural effusion triglyceride/serum triglyceride ratio indicate a positive result in patients with chylothorax on lymphoscintigraphy, with the cutoff values of 2.870 mmol/L and 4.625 aiding in the diagnosis.

Transudative chylothorax and frailty: a diagnostic and therapeutic challenge

Transudative chylothoraces are a rare entity and their management in the presence of multiorgan dysfunction and frailty is complex. A woman in her 90s was investigated during acute hospital admission and found unexpectedly to have a transudative chylothorax secondary to cryptogenic cirrhosis. Not all chylothoraces have the classically described milky appearances and a high index of suspicion is vital in determining appropriate investigation and management. Our patient required repeated thoracocentesis and subsequently chose to be discharged from hospital with comfort care. Management of non-malignant pleural effusions can be challenging. Case reports surrounding the management of transudative chylothoraces in particular are scarce. Establishing patient priorities and openly explaining the uncertainty regarding prognosis and potential therapeutic options is paramount in this complex and changing field.

Chylothorax associated with pulmonary compressive atelectasis in an emperor tamarin (Saguinus imperator)

Chylothorax is the accumulation of lymph in the thoracic cavity, and it has never been reported in neotropical primates. An emperor tamarin died and at necropsy chylothorax associated with pulmonary compressive atelectasis was diagnosed. Idiopathic chylothorax can be a cause of respiratory insufficiency and death in tamarins.

A Very Uncommon Case of Transudative Chylothorax: A Case Report and Literature Review

The presence of chyle in the pleural cavity is referred to as chylothorax. Exudative chylothorax is usually related to damage or obstruction of the lymphatic vasculature with subsequent leakage into the pleural space. In contrast, transudative chylothorax is related to increased hydrostatic pressure caused by elevated intra-abdominal pressure, which leads to the translocation of chylous fluid into the pleural space. Cirrhosis is the most common cause of transudative chylothorax, commonly presenting with ascites and portal hypertension. To the best of our knowledge, isolated transudative chylothorax as a consequence of cirrhosis is exceptionally rare and has been scarcely reported in the literature. We herein report a female patient in her fifties who presented to our hospital with isolated unilateral transudative hepatic chylothorax, with no clinical evidence of cirrhosis or any stigmata of portal hypertension at the time of presentation.

Small Chyle Leak Localized on Lymphoscintigraphy with Single-Photon Emission Computed Tomography-Computed Tomography

Chylothorax refers to the accumulation of triglyceride-rich fluid (chyle) within the pleural space. We described a case of spontaneous chylothorax in an infant. Lymphoscintigraphy was performed with 99 m-Tc sulfur colloid which showed tracer accumulation into thoracic cavity, and single-photon emission computed tomography/CT (SPECT/CT) revealed leak in the thoracic duct at D8 vertebral level as the cause. We, thus, emphasize the role of lymphoscintigraphy with SPECT/CT in identification of cause and guiding the management of chylothorax, especially when surgical treatment is planned.

Pleural fluid milkshakes: three cases with different aetiologies

In clinical practice, chylothorax is usually suspected in any patient with milky pleural fluid. However, contrary to popular belief, milky appearance of pleural fluid is seen in less than half of patients with chylothorax. A high index of suspicion for chylothorax is therefore needed in any turbid, bloody, or serosanguinous effusions of unclear aetiology. In this case series, we present three patients with biochemically proven chylothorax: each with a different presentation, pleural fluid appearance, underlying cause, management strategy and clinical outcome. The first patient developed 'milky' chylothorax secondary to lymphoma while the second patient's 'yellow' chylothorax is related to pleural tuberculosis. The final patient suffered from 'pink' chylothorax in the setting of systemic amyloidosis. In each of the cases, prompt diagnosis of chylothorax followed by efforts to elucidate the underlying cause are crucial steps to guide subsequent management with the main aim to ensure a better clinical outcome.

Recurrent chylothorax as a consequence of esophageal stent

Incidence of chylothorax post-esophageal stenting has not been reported. We present a 40-year-old female with metastatic breast cancer who presented with dyspnea. She was recently hospitalized for dysphagia secondary to a mediastinal mass requiring an esophageal stent. CT chest now reported large bilateral pleural effusions. A benign chylothorax was drained from the right side. After persistent high-output drainage, a review of her CT chest revealed thoracic duct impingement by the esophageal stent. The stent was retracted proximally, and pleural fluid output subsequently decreased. Repeat fluid analysis revealed a transudative effusion. This is the first reported case of esophageal stenting causing reversible chylothorax.

Letter to Editor regarding "Unusual Presentation of Spontaneous Chylothorax"

How to cite this article: Varghese AR, Jindal A. Letter to Editor regarding "Unusual Presentation of Spontaneous Chylothorax". Indian J Crit Care Med 2022;26(11):1225.

Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

Non-traumatic chylothorax: diagnostic and therapeutic strategies

Non-traumatic chylothorax refers to accumulation of chyle in the pleural space in the absence of any traumatic disruption to the thoracic duct. Chyle originates from the intestines and is transported via the thoracic duct into systemic circulation. The anatomical course of the thoracic duct is complex with considerable variation; therefore, development of chylothorax is dependent on the site and level of the thoracic duct defect. Non-traumatic chylothorax is associated with a wide range of medical disorders, but malignancy accounts for three-quarters of cases. In up to 9% of cases, the aetiology remains unknown (termed idiopathic chylothorax). Gross appearance of pleural fluid is neither sensitive nor specific enough to diagnose chylothorax; therefore, biochemical analysis of the pleural fluid is required. Pleural fluid triglyceride level >1.24 mmol·L⁻¹ (110 mg·dL⁻¹) with a cholesterol level <5.18 mmol·L⁻¹ (200 mg·dL⁻¹) is diagnostic of chylothorax. In borderline cases, lipoprotein electrophoresis can help confirm the diagnosis by detecting chylomicrons in the pleural fluid.

Once the diagnosis of chylothorax is confirmed, the next step is to find the cause and identify the leakage point, for which various lymphatic specific radiological investigations may have an important role. There is paucity of data on the most suitable approach to manage non-traumatic chylothoraces and treatment often depends on the underlying cause. In general, conservative treatment is tried first, usually for a limited time, before considering more invasive measures. A multidisciplinary approach is recommended with close liaison among the respiratory physicians, thoracic surgeons, oncologists, interventional radiologists, dietitians and pharmacists.

Non-traumatic chylothorax is associated with a myriad of medical disorders. Lipid analysis of pleural fluid is required to confirm the diagnosis. A multidisciplinary approach is recommended for the effective management of non-traumatic chylothorax. https://bit.ly/3Nssb7n

Postoperative Chylothorax in Neonates and Infants after Congenital Heart Disease Surgery-Current Aspects in Diagnosis and Treatment

Postoperative chylothorax is a rare complication following cardiac surgery for congenital heart disease (CHD) in the pediatric population, including neonates and infants. Multiple mechanisms are involved in the development of postoperative chylous effusions, mainly the traumatic injury of lymphatic vessels, systemic venous obstruction and dysfunction of the right ventricle. In this review, we focus on the existing evidence regarding the definition and diagnosis of postoperative chylothorax in children with CHD, as well as current therapeutic approaches, both nutritional and interventional, for the management of these patients. As part of nutritional management, we specifically comment on the use of defatted human milk and its effect on both chylothorax resolution and patient growth. A consensus with regard to several key aspects of this potentially significant complication is warranted given its impact on the cost, morbidity and mortality of children with CHD.

Chronic nonchylous lymphatic pleural effusion in a bottlenose dolphin (Tursiops truncatus)

CASE DESCRIPTION

A 19-year-old male bottlenose dolphin (Tursiops truncatus) presented with inappetence and avoidant behavior.

CLINICAL FINDINGS

Ultrasound revealed a large-volume left-sided pleural effusion, which was consistent with chronic nonchylous lymphatic effusion and mild chronic hemorrhage by cytology. Computed tomography identified ipsilateral rib fractures, atelectasis, nodular pleuritis, marginal lymph node enlargement, and suspected dilation of the thoracic duct and internal thoracic veins. Fifteen lipids were significantly higher in serum of the dolphin as compared with controls (n = 3) using nontargeted lipidomics.

TREATMENT AND OUTCOME

A series of thoracentesis procedures were performed. Follow-up CT demonstrated marked reduction in pleural effusion with persistence of thoracic duct dilation and mass-like areas of pleural thickening. Ultrasonographic resolution of pleural effusion occurred 14 months after presentation; however, recrudescence was noted 5 months later. Over a total of 24 months, 21.52 L of pleural effusion was removed. Despite the presence of pleural effusion, the patient was clinically stable during this time and quality of life was considered good on the basis of continuous animal welfare evaluations. Humane euthanasia was elected following acute clinical decline 27 months after initial diagnosis. Necropsy confirmed severe pleural effusion, chronic severe pleural fibrosis with chronic hemorrhage, and mediastinal fibrosis with entrapped lymph nodes and thymic tissue.

CLINICAL RELEVANCE

Pleuritis and effusion were suspected sequelae of previous rib fractures. To our knowledge, this is the first report of nonchylous lymphatic pleural effusion with repeated pleural drainage and diagnostic imaging for clinical management in a bottlenose dolphin.

Lipoprotein profile of pleural and peritoneal transudates in dogs and cats

BACKGROUND

Current diagnostic evaluation of transudative effusions rarely aids in identifying an underlying etiology. Lipoproteins in the fluid might reflect the site or nature of vessel involvement.

OBJECTIVES

Improve the classification and diagnostic utility of pleural and peritoneal transudates in dogs and cats by investigating lipoprotein patterns in effusions. Compare these patterns with other peritonaeal and pleural fluid variables and underlying diseases.

ANIMALS

Samples of transudates and serum from 18 cats and 37 dogs with transudative effusion (total nucleated cell count [TNCC] <5000 cells/μL) were analyzed.

METHODS

Lipoprotein fractions, triglyceride, and cholesterol (CHO) concentrations were prospectively determined in paired fluid and serum samples. Standard fluid measurements were retrospectively collected.

RESULTS

Two distinct fluid lipoprotein patterns were noted. Fluids rich in VLDL+IDL were associated with chronic kidney disease, acquired portosystemic shunts or protein-losing enteropathy (group I). Fluids rich in denser lipoproteins were associated with underlying heart disease, caudal vena cava syndrome or intracavitary neoplasia (group II). Group I and group II also had significant differences between fluid concentrations of CHO (x̄ = 8 vs 110 mg/dL) and TP (x̄ = 0.6 vs 3.8 g/dL), respectively. Five peritoneal transudates were triglyceride-rich (>100 mg/dL) and associated with pancreatitis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Protein-poor (TP <1.5 g/dL) and protein-rich (TP >2.5 g/dL) transudates were associated with distinct lipoprotein patterns and specific groups of disease. Effusions secondary to pancreatitis might be transudative and rich in triglycerides.

A rare clinical presentation of Waldenström Macroglobulinemia mimicking lung cancer

Waldenström macroglobulinemia rarely presents as pulmonary symptoms, and even rarer as chylothorax. We present a patient who presented with bilateral pleural effusion and a 30 mm solid lesion in the lung. Biochemical analysis of the pleural fluid revealed chylothorax. The 18-fluorodeoxygenase positron emission tomography, bronchoscopy, endobronchial ultrasound, and cytological examination of the pleural fluid, showed no apparent cause of the chylothorax. The diagnostic breakthrough was made with flow cytometry of the pleural fluid, which revealed a small group of clonal B-cells. Biopsy from the parietal pleura and bone marrow led to the diagnosis Waldenström macroglobulinemia. This demonstrates that flow cytometry should be considered when routine diagnostics do not lead to a reach a specific diagnosis.

Coagulation in Lymphatic System

The lymphatic system maintains homeostasis of the internal environment between the cells in tissues and the blood circulation. The coagulation state of lymph is determined by conditions of coagulation factors and lymphatic vessels. Internal obliteration, external compression or abnormally increased lymphatic pressure may predispose to localized lymphatic coagulation. In physiological conditions, an imbalance of antithrombin and thrombokinase reduces lymphatic thrombosis. However, the release of factor X by lymphatic endothelium injury may trigger coagulation casacade, causing blockage of lymphatic vessels and lymphedema. Heterogeneity of lymphatic vessels in various tissues may lead to distinct levels and patterns of coagulation in specific lymphatic vessels. The quantitative and qualitative measurement of clotting characteristic reveals longer time for clotting to occur in the lymph than in the blood. Cancer, infections, amyloidosis and lymph node dissection may trigger thrombosis in the lymphatic vessels. In contrast to venous or arterial thrombosis, lymphatic thrombosis has rarely been reported, and its actual prevalence is likely underestimated. In this review, we summarize the mechanisms of coagulation in lymphatic system, and discuss the lymphatic thrombosis-related diseases.

Chylothorax and Pseudochylothorax

Classically, both chylothorax and pseudochylothorax present as a pleural effusion with a characteristic milky white appearance to the pleural fluid. Although both are rare causes of pleural effusion, they have distinct etiologies and clinical implications, and as a result require different management strategies. Pleural fluid analysis of cholesterol and triglyceride levels is key to differentiating the 2 entities from one another and then guide the clinician to determine the best next steps in evaluation and management.

Milky pleural effusion in a neonate and approach to investigating chylothorax

Neonatal chylothorax is a rare presentation leading to significant respiratory distress, thus requiring timely diagnosis. A preterm neonate was resuscitated and ventilated, following which she clinically improved but subsequently developed respiratory distress with a right-sided pleural effusion. Interestingly, thoracentesis fluid appeared ‘milky’ with elevated triglycerides and lymphocytes, suggesting chylothorax. As fluid triglyceride level was lower than the established diagnostic criterion for chylothorax (1.24 mmol/L), a high fluid-to-serum triglyceride ratio was used as a surrogate diagnostic marker, later confirmed by lipoprotein electrophoresis. As observed in the index patient, a critically ill neonate would have a lower-than-average fat intake leading to less chylomicron production, thus lower triglyceride levels in chyle than expected, which may still fail to meet the amended cut-off limit. This case highlights the challenges in diagnosing neonatal chylothorax due to the lack of age-specific triglyceride levels in chyle and low oral fat intake in critically ill patients.

Dietary treatment of congenital chylothorax with skimmed breast milk

BACKGROUND

Congenital chylothorax (CC) is a rare but potentially life-threatening condition in newborns. It is defined as an accumulation of chyle in the pleural cavity. The few publications regarding medical management and therapeutic dietary intervention motivated us to share our experience.

METHODS

Neonates diagnosed with congenital chylothorax and treated at Innsbruck Medical University Hospital between 2013 and 2020 (n = 6, gestational age: 36 3/7, 32 5/7, 36 4/7, 35 0/7, 35 4/7, 37 3/7 weeks) were eligible for this report. The cornerstones of treatment for chylothorax conventionally consist of chest tube drainage (CTD), respiratory support, dietary restriction of long-chain triglycerides (LCT) or total parenteral nutrition (TPN). In further course the introduction of a medium-chain triglyceride (MCT)-based formula followed by an overlapping switch to a formula with low LCT and high MCT, containing the essential long-chain fatty acids (LCFA), is attempted. In three patients we used fat-modified (skimmed) breast milk to provide a high protein and low fat diet and to avoid the discontinuation of breast milk.

RESULTS

The outcome of an early introduction of LCFA in the form of skimmed breast milk after resolution of chylothorax diverse. One patient had a favourable outcome, meaning no recurrence of pleural effusion, adequate weight gain and a content mother, while another patient had a relapse of pleural effusion after the administration of skimmed milk and was therefore transitioned back to Basic F® . The CC of patient 5 was difficult due to Noonan syndrome. Two weeks after the introduction of skimmed breast milk the mother wanted to stop to express breast milk, so nutrition was changed to Basic F®.

CONCLUSION

The first-line therapy of chylothorax is a combination of respiratory stabilization and dietary modification. The use of skimmed breast milk is advisable in CC and feasible by means of a simple milk defatting procedure. It offers benefits to mothers who wish to resume breast feeding after resolution of chylothorax and has proven positive effects, above all in preterm infants as optimal nutrition with protective components superior to formula feeding. However, the nutritional analysis of the skimmed milk and the correlation to a re-accumulation of pleural fluid remains a question to be answered.

Intracardiac malignant nonchromaffin paraganglioma (chemodectoma) in a cat

A 5-year-old male castrated Domestic Shorthair cat was presented to a veterinary specialty hospital for evaluation of large-volume pleural effusion. Echocardiography revealed a large intracardiac mass at the level of the interatrial septum impairing right atrial inflow resulting in lymphocytic pleural effusion and ascites. Differential diagnoses included lymphoma, hemangiosarcoma, rhabdomyosarcoma, chemodectoma, neurofibrosarcoma, myxoma, metastatic carcinoma or intracardiac thrombus, abscess or granuloma. Due to poor long-term prognosis and recurrent, large-volume pleural effusion, the cat was humanely euthanized. The heart was submitted for histopathologic evaluation. The mass was subsequently determined to be a malignant extra-adrenal nonchromaffin paraganglioma (chemodectoma) arising from the pulmonary trunk near its bifurcation in the region of the glomus pulmonale. Chemodectomas are rare in cats and to the authors' knowledge, there are no reports of one originating from the glomus pulmonale.

The milky way

Mediastinal masses may present with signs and symptoms due to either compression of mediastinal structures or systemic effects of the underlying disease. The present case highlights the advantages of interventional pulmonology in the diagnosis of lymphoma as a cause of chylothorax and superior vena cava syndrome.  

[Modern Treatment Options for Postoperative Chylothorax: a Systematic Review]

BACKGROUND

 Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis.

MATERIAL AND METHODS

 The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations.

RESULTS

 The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3-90 %). Non-invasive or semi-invasive procedures are successful in 50 to 100 % of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100 %. The morbidity and mortality rate can reach values up to 25 %.

CONCLUSION

 Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

Chylothorax after coronary artery bypass grafting: Is it always early?

BACKGROUND

Chylothorax is a rare complication of cardiothoracic surgical interventions and usually presents early in the postoperative period.

MATERIALS AND METHODS

We present a case of 63 years female who presented with chylothorax 5 months after undergoing coronary artery bypass surgery.

DISCUSSION AND CONCLUSION

Chylothorax should be considered in patients with recurrent pleural effusions even if the effusions do not have the typical milky appearance. Although chylothorax in most cases will present early in post operative period, it should be remembered that it can present in a delayed manner. Morbidity and health care costs associated with this entity can be remarkably high and therefore it is of great importance to diagnose and treat it.

Chylothorax as a complication of Waldenström macroglobulinaemia with a patient's perspective

Chylothorax has rarely been reported as a pleuropulmonary complication of Waldenström macroglobulinaemia (WM). In general, when a unilateral effusion is discovered particularly in patients with a history of cancer or active malignancy, a broad differential including chylothorax needs to be considered. We present the case of a 50-year-old woman found to have chylothorax secondary to progression of WM as confirmed by cytology and presence of MYD88 L265P mutation in the pleural fluid specimen and subsequent resolution with chemotherapy. This review centres particularly on non-traumatic causes of chylothorax with a focus on WM and includes a unique patient perspective.

A 67-Year-Old Woman With Abdominal Pain and Dyspnea

CASE PRESENTATION

A 67-year-old woman presented to her primary physician with a year of periumbilical abdominal discomfort with diarrhea, bloating, and unintentional weight loss. While undergoing workup for the abdominal pain, she presented to the ED with dyspnea that worsened over a few weeks. She had no associated chest pain, lower extremity edema, fevers, or chills, but endorsed orthopnea. The patient's medical history included hypothyroidism and diabetes mellitus. Her family history was significant for coronary disease in her father and hypertension in her mother. She had no recent travel; she is a nonsmoker and rare alcohol drinker. She worked in administration.

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series

BACKGROUND

In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

OBJECTIVE

To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

MATERIALS AND METHODS

We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

RESULTS

Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

CONCLUSION

Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.

Thoracic Empyema Secondary to Congenital Chylothorax in a 14-Month-Old Boy with Noonan Syndrome

Thoracic empyema usually occurs as a complication of bacterial pneumonia, but in rare cases, it is caused by hematogenous dissemination secondary to nonpulmonary diseases. Congenital chylothorax or chylothorax in children is associated with maldevelopment of the lymphatic system, nonimmune hydrops fetalis, several syndromes including Down syndrome, Noonan syndrome, or Turner syndrome, a complication of thoracic surgery, right heart failure with high central venous pressure, or tumors. There are very few reports of empyema associated with preexisting chylothorax. In the present study, we describe a rare case of thoracic empyema associated with congenital chylothorax and supravalvular pulmonary stenosis associated with clinically diagnosed Noonan syndrome. It is necessary to closely monitor patients with chylothorax because they are at risk of developing severe lung infections, such as pleural empyema or lung abscesses.

Bilateral Chylothorax and Chylous Ascites: A Rare Presentation of an Uncommon Disorder

We describe the case of a 62-year-old female who presented with gradually progressing abdominal distension and dyspnea. Computed tomography (CT) chest and abdomen revealed large bilateral pleural effusions with large ascites, a mid-abdominal mass, and peritoneal carcinomatosis. Pleural and peritoneal tap revealed chylous fluid, and the biopsy findings from abdominal mass were consistent with follicular lymphoma. We then discuss a review of the literature and diagnoses for bilateral chylothorax and chylous ascites.

Differential diagnosis of chylothorax in therapeutic practice

The article is devoted to the differential diagnosis of chylous pleural effusion. The spectrum of traumatic and non-traumatic causes of chylothorax is discussed in detail. Examples of necessary diagnostic measures are given for the accumulation of milky fluid in the pleural cavity in order to verify chylothorax.

Chylothorax post transaxillary first rib resection for thoracic outlet syndrome

We present a patient who developed high output chyle leak post left transaxillary first rib resection for venous thoracic outlet syndrome. The high output chylorrhoea was successfully treated by conservative measures, bed rest, parenteral nutrition and low-fat diet. The patient was discharged after an 18-day hospital stay with a complete resolution of his chylous fistula prior to discharge. This is the first documented chylothorax post transaxillary first rib resection likely due to anomalous chyle anatomy.

Use of Octreotide in association with talc poudrage for the management of a severe chylothorax: A case report

INTRODUCTION AND IMPORTANCE

Chylothorax is an uncommon form of pleural effusion characterized by the presence of chylomicrons, triglycerides and cholesterol in the physical and chemical examination of the pleural fluid. It may have poor prognosis if not properly treated. Currently, conservative measures are the first line of treatment for managing chylothorax. The aim of our study is to show and suggest the use of octreotide in association with talc poudrage as good option to manage post-operative a severe chylothorax.

CASE PRESENTATION

A 59-year-old male patient who underwent a replacement of the ascending aorta, aortic hemiarch and surgery of the aortic valve for aortic dissection showed a severe pleural effusion three months after surgery. Because the physical and chemical examination of the pleural fluid revealed high levels of triglycerides and cholesterol, a conservative treatment with pleural drainage, TPN and nihil per os was attempted, with the introduction of 0.3 mg/die of octreotide on day thirty-four. With the application of talc poudrage, the chylothorax completely resolved.

CLINICAL DISCUSSION

Octreotide has been shown to significantly decrease chylous effusion in many studies, but the dose and duration of therapy have not yet been defined. Our patient responded partially to octreotide after two days of treatment, with the drainage leak reduced to less than 100 mL/day.

CONCLUSION

After octreotide treatment associated with talc poudrage, the drainage leak was drastically reduced, suggesting that this could be a useful approach in the management of severe chylous leaks.

Chylothorax after Lung Cancer Surgery: A Key Factor Influencing Prognosis and Quality of Life

Chylothorax is caused by the accumulation of chylous fluid in the pleural cavity due to the injury of the thoracic duct or its tributaries. Chylothorax following lung cancer surgery, especially pulmonary resection and mediastinal lymph node dissection, is a raw potential postoperative complication as previously reported. Chylothorax might lead to a high mortality rate if not addressed in a timely fashion. This article reviews the anatomy of the thoracic duct, risk factors of postoperative chylothorax, diagnoses and management with chylothorax, and intraoperative prevention of chylothorax. With the development of researches on postoperative chylothorax, more effective treatment and prevention measures need to be proposed to better solve this clinical problem.

White lung with milky effusion

Thoracic duct injury is a rare complication of dorsal spine operations. Ultrasound chest plays an important tool for rapid diagnosis of acute dyspnea, drainage of massive effusion, and daily follow-up. Conservative treatment of postoperative chylous with measures to decrease chylous formation can lead to a resolution of chylothorax.

Recurrent non-traumatic idiopathic chylothorax: a diagnostic dilemma with therapeutic challenge

Chylothorax is an uncommon pleural effusion characterized by the presence of chyle in the pleural space. Malignancy, trauma, and infections such as tuberculosis and filariasis can result in chylothorax. The chyle is an odourless and white liquid; however, around 50% of chylothorax is not milky (serosanguineous) and 10% of chylothorax is idiopathic which can pose a diagnostic dilemma. We propose a systematic approach which includes pleural fluid triglycerides and cholesterol for all undiagnosed pleural effusion. The case highlights the diagnostic dilemma as well as therapeutic challenges.

Esophageal cancer surgery: review of complications and their management

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

MRI Assessment of Chylous and Nonchylous Effusions: Use of Multipoint Dixon Fat Quantification

Background Diagnosis of chylous effusions normally requires invasive paracentesis. Purpose To assess whether MRI with multipoint Dixon fat quantification allows for noninvasive differentiation of chylous and nonchylous ascites and pleural effusions. Materials and Methods Phantom, ex vivo, and in vivo MRI examinations were performed by using a commercially available multipoint Dixon pulse sequence with a 1.5-T MRI system. Fat fraction values were measured with a region of interest-based approach on reconstructed maps. For phantom evaluation, eight titrated fatty fluid solutions (nonhuman samples) with varying triglyceride content (145-19 000 mg/dL [1.64-214.7 mmol/L]) were examined. For ex vivo evaluation, 15 chylous and five nonchylous study participant fluid samples were examined. In a prospective study performed from June 2016 to February 2018, 29 study participants with known chylous (n = 17) and nonchylous (n = 12) effusions were evaluated with MRI. All clinical samples underwent laboratory testing for triglyceride level, total protein level, white blood cells, and red blood cells. Laboratory values were correlated with fat fraction values; the optimal fat fraction threshold was determined to differentiate chylous and nonchylous fluids. Results Phantom analysis showed that fat fraction values correlated with triglyceride content (r = 0.99, P < .001). In ex vivo studies, multipoint Dixon-derived fat fraction was higher in chylous versus nonchylous fluids (mean, 2.5% ± 1.2 [standard deviation] vs 0.8% ± 0.2; P = .001). Fat fraction was correlated with triglyceride content (r = 0.96, P < .001). For in vivo studies, fat fraction was greater for chylous versus nonchylous fluids (mean, 6.2% ± 4.3 vs 0.6% ± 0.6; P < .001). In vivo fat fraction was correlated with triglyceride content (r = 0.96, P < .001). Use of a fat fraction cutoff value greater than 1.8% yielded a sensitivity of 14 of 17 (82% [95% confidence interval (CI): 57%, 97%]) and a specificity of 12 of 12 (100% [95% CI: 74%, 100%]) for differentiation of chylous and nonchylous effusions. Conclusion MRI can help identify chylous versus nonchylous ascites and pleural effusions through use of multipoint Dixon fat quantification. © RSNA, 2020 Online supplemental material is available for this article.

Spontaneous Chylothorax following Septic Pulmonary Embolization

Chylothorax is the occurrence of chyle (lymph) in the pleural cavity secondary to damage of the thoracic duct. It is a rare form of pleural effusion which appears as a milky white turbid fluid. Malignancy is the leading cause of nontraumatic chylothorax while inadvertent surgical injury to the thoracic duct is the major cause of traumatic chylothorax. We report a case of spontaneous left-side chylothorax following septic pulmonary embolization (SPE) with Methicillin-Resistant Staphylococcus aureus (MRSA). This is a rare case of a nonmalignant, nontraumatic, and nontuberculous spontaneous chylothorax which was conservatively treated with fibrinolysis and diet modification.