Transudative Chylothorax in a Patient with Pulmonary Hypertension

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Nadir Görülen bir Şilotoraks Olgusu / A Rare Case of Chylothorax

Transudative Chylothorax

in a Patient with Pulmonary Hypertension

Pulmoner Hipertansiyonlu

Bir Hastada Gelişen Transüda Şilotoraks

DOI: 10.4328/JCAM.3690 Received: 26.06.2015 Accepted: 12.08.2015 Printed: 01.10.2015 J Clin Anal Med 2015;6(suppl 5): 665-7 Corresponding Author: Sedat Kuleci, Göğüs Hastalıkları Anabilim Dalı, Çukurova Üniversitesi Tıp Fakültesi, Balcalı, Adana, Türkiye.

GSM: +905072516981 E-Mail: skuleci@gmail.com / skuleci@cu.edu.tr

Özet

Plevral boşlukta şilöz sıvının toplanması olarak tanımlanan şilotoraks,

araların-da pulmoner hipertansiyonun (PH) araların-da bulunduğu çeşitli patolojiler nedeniyle

geli-şen ve nadir görülen bir klinik tablodur. Şimdiye dek pulmoner hipertansiyona bağlı

olarak gelişen sadece bir kaç transüda şilotoraks olgusu bildirilmiştir. Bu sunumda

kapak patolojisi ve sağ kalp yetmezliğine bağlı PH sonucu gelişmiş olan, 70

yaşın-da bir kadınyaşın-da saptanan bir transuyaşın-datif şilotoraks olgusu sunulmuştur.

Anahtar Kelimeler

Transüda Şilotoraks; Pulmoner Hipertansiyon; Sağ Kalp Yetmezliği

Abstract

Chylothorax, presence of chyle in the pleural space, is an infrequent clinical form

of pleural efusion developed due to several pathologies, including pulmonary

hy-pertension. Since now, very few clinical cases of transudative chylothorax due to

pulmonary hypertension have been reported. In this report, we present a

transu-dative chylothorax case of 70-year-old female patient with pulmonary

hyperten-sion due to cardiac valvular insuiciency and right heart failure.

Keywords

Transudative Chylothorax; Pulmonary Hypertension; Right Heart Failure Sedat Kuleci, Oya Baydar, Efraim Güzel, İsmail Hanta Göğüs Hastalıkları Anabilim Dalı, Çukurova Üniversitesi Tıp Fakültesi, Adana, Türkiye

Bu olgu Türk Toraks Derneği’nin 1-5 Nisan 2015 tarihleri arasında yapılan 18. Yıllık kongresinde poster olarak sunulmuştur.

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Introduction

Chylothorax is deined by the presence of chyle in the pleural space. [1, 2]. The accumulation of chyle in the pleural cavity may be due to rupture of the thoracic duct and/or its tributaries, leakage from the pleural lymphatics and/or collateral vessels, or transdiaphragmatic low of chyle from the peritoneal cav-ity in patients with chylous ascites [2]. Situations evoking any of these mechanisms represent chylothorax causes (Table 1), which are grouped into four major categories: trauma, malig-nancy, miscellaneous and idiopathic [1 - 4]. Transudative chylo-thorax has been reported between %15 - %32 of all chylochylo-thorax cases, principally among cirrhosis cases [5, 6]. In this report, we present a case of transudative chylothorax possibly developed from pulmonary hypertension due to cardiac valvular insui-ciency and right heart failure.

Case Report

A seventy years old, non-smoker female patient admitted to our hospital with symptoms of dyspnea, right-sided chest pain for last 6 months. She had a history of mitral valve replacement in 1993 and she has been anticoagulated since then. Physical examination revealed signs of right-sided pleural efusion. On chest radiography, pleural efusion covering nearly half of the right hemithorax was observed (Figure 1). Hematologic and bio-chemical laboratory indings were all normal. But, only, the brain

natriuretic peptide (BNP) level was found very high (4630 pg/ mL (N: 0-197 pg/mL)). Echocardiographic evaluation was re-ported as: “Normal ventricular contractility (Ejection fraction: 60%), prosthetic mitral valve, severe pulmonary hypertension (sPAP: 115mmHg) and tricuspit insuiciency, moderate aortic insuiciency, dilatation of let atrium, and right atrium and ven-tricle”. When irst thoracentesis was performed, pleural efusion sample revealed transudative characteristics (Table 2).

Microbi-ologic and cytMicrobi-ologic laboratory indings of pleural efusion were found all normal. Calcium channel blockers and diuretics were administered for cardiac problems. In clinical follow-up, on 12th of hospital day, pleural efusion level was found to be increased on chest x-ray and clinically, she was deteriorated (Figure 2).

Closed chest tube drainage was performed on right hemithorax for relieving excessive pleural efusion. Since the color of pleu-ral efusion in chest tube appeared to be milky, pleupleu-ral efusion was evaluated biochemically for chylothorax, also. Triglyceride level was found three fold higher than normal, but it was still transudative (Table 2).

Oral feeding is discontinued; a diet with low triglyceride levels was initiated. Somatostatin was ordered at dose of 6 mg/day. She was evaluated for possible malignancies with thoracic-ab-dominal and pelvic computerized tomography. Radiological and clinical indings were normal except a 5 cm of pleural efusion and enlarged pulmonary artery. The patient was followed for two months in the clinic ward.

Figure 1. Chest x-ray of the patient at irst admission

Figure 2. Chest x-ray on 12th day of admission Table 1. Etiopathogenetic classiication of chylothorax

A. Traumatic C. Miscellaneous

a. Iatrogenic a. Increased lymph volume +/or i. Surgical abnormal lymphatic lumen ii. Non-surgical i. Lymphatic disorders - congenital b. Non-Iatrogenic ii. Lymphatic disorders - acquired B. Malignancy b. Lymphatic obstruction a. Iniltration i. Intraluminal obstruction b. lymphatic obstruction ii. External pressure

c. Increased venous pressure d. Chylous ascites D. Idiopathic

Table 2. Laboratory indings of two thoracenteses

Charactereristic 1st Thoracentesis 2nd Thoracentesis Pl. Ef. Serum Ratio Pl. Ef. Serum Ratio

LDH* [U/L) 44 172 0,25 185 320 0,57

Total Protein [g/dl) 1,7 6,5 0,26 2,7 5,8 0,46

Glucose [mg/dl) 102 115 146 155

pH 8,0 8,5

Cholesterol [mg/dl) 41

Triglyceride [mg/dl) 627

666

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Ater clinical stabilization and radiological improvement are achieved, chest tube drainage discontinued. She was dis-charged from hospital ater two months of treatment period. She has been still following up by out-patient clinics of chest disease.

Discussion

Chylothorax is not a common form of pleural efusion. Gener-ally, chylothorax is taken in account, if pleural luid is in milky appearance. It should be noted that not all chylous pleural ef-fusions appear milky white. Almost 50% of chylothorax cases present as bloody, yellow or green, turbid, serous or serosan-guineous efusions [1 - 3]. Chylothoraces are usually charac-terized by all three of the following: 1.) a triglyceride level of more than 110 mg/dL; 2.) a ratio of pleural luid to the serum triglyceride level of more than 1.0; and 3.) a ratio of the pleural luid to serum cholesterol level of less than 1.0 [7].

And also, chylothorax does not always meet the exudative crite-ria. Transudative form has been reported between %15 - %32 in several studies due to various pathologies [5, 6]. In a review of 2005, 15 cases have been reported as transudative chylothorax, which can be attributed to cirrhosis, nephrosis or heart failure [8]. However, only two cases of transudative chylothorax due to pulmonary hypertension secondary to right heart failure have been presented at “International PHA Conference and Scientiic Sessions” in 2014 and “American Thoracic Society International Conference” in 2010. Our patient is a case of transudative chy-lothorax possibly due to pulmonary hypertension secondary to cardiac valvular insuiciency and right heart failure.

The fundamental mechanism behind chylothorax is the leakage of chyle into the pleural space. Trauma to the thoracic duct is the most common mechanism of chylothorax. Among the pa-tients with chylothorax with a known cause, lymphoma has been considered the most frequent one, followed by metastatic carcinoma [7]. However, the increasing number of intrathoracic surgical procedures and the frequent use of the great veins for total parenteral nutrition and hemodynamic monitoring have contributed to a recent increase in the number of iatrogenic chylothoraces, which may have exceeded the number of those caused by malignancy [3, 4].

The possible mechanism for transudative chylothorax in PAH patients is poorly understood. It is postulated that acute in-creased right-sided heart pressures led to elevated pressure in the superior vena cava and back pressure into the thoracic duct. Reducing the pressure in the system resolved the chylothorax [8].

Our patient had no recent history trauma or invasive procedure, except thoracentesis and closed tube drainage ater hospital-ization. Biochemical evaluation of pleural efusion for the sec-ond thoracentesis revealed transudative chylothorax (Table 2). All cytological and microbiological evaluations were found nor-mal. On computerized tomography of the whole body; no lymph-adenopathy was determined, and neither granulomatous and cystic diseases, nor parenchymal diseases have been detected in thoracic evaluation. On echocardiographic evaluation, right heart failure due to mitral valve disease and pulmonary arterial hypertension (sPAP=115 mmHg) have been detected. With all these clinical, radiological and laboratory indings, patient has

been accepted as transudative chylothorax due to PAH. Therapeutic modalities for chylothorax include oral intake dis-continuation, dietary regimens include a high protein-low fat diet with limited oral intake, supplemented with medium chain triglycerides, or fasting plus total parenteral nutrition, soma-tostatin infusion, thoracic duct embolization, tube drainage, direct ligation of the thoracic duct, mass ligation of the supra-diaphragmatic thoracic duct, pleurovenous or pleuroperitoneal shunting, pleurectomy, pleurodesis with glue or talc and radio-therapy [3, 4].

In our patient, we preferred chest tube drainage, oral intake avoidance, somatostatin infusion, diuretics and supplementa-ry modalities. By these treatment options, she was recovered considerably in a period of two months and is still under serial clinical control.

In conclusion, although very rare, evaluation of transudative pleural efusion for chylothorax should be considered in any pa-tient with pulmonary hypertension with pleural efusion in clini-cal practice.

Competing interests

The authors declare that they have no competing interests.

References

1. Huggins JT. Chylothorax and Cholesterol Pleural Efusion. Semin Respir Crit Care Med 2010;31(6):743-50.

2. Skouras V, Kalomenidis I. Chylothorax: diagnostic approach. Curr Opin Pulm Med 2010;16:387-93.

3. McGrath EE, Blades Z, Anderson PB. Chylothorax: Aetiology, diagnosis and ther-apeutic options. Respir Med 2010;104:1-8.

4. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007;32:362–69.

5. Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural luid characteristics of chylothorax. Mayo Clin Proc 2009;84:129–33.

6. Agrawal V, Doelken P, Sahn SA. Pleural luid analysis in chylous pleural efusion. Chest 2008;133:1436–41.

7. Romero S. Nontraumatic chylothorax. Curr Opin Pulm Med 2000;6:287–91. 8. Diaz-Guzman E, Culver DA, Stoller JK. Transudative chylothorax: report of two cases and review of the literature. Lung 2005;183:169–75.

How to cite this article:

Kuleci S, Baydar O, Guzeli E, Hanta İ. Transudative Chylothorax in a Patient with Pulmonary Hypertension. J Clin Anal Med 2015;6(suppl 5): 665-7.

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