Mujer de 71 años con edema cervical doloroso y derrame pleural bilateral / No disponible

El derrame pleural de tipo exudado tiene múltiples etiologías, siendo las más frecuentes los derrames paraneumónicos (50-70%), las neoplasias (15-35%) y la tuberculosis. Presentamos el caso de una mujer de 71 años con edema doloroso en la región laterocervical izquierda y radiografía de tórax con aumento de partes blandas en dicha región y pinzamiento de senos costofrénicos, que tras los estudios complementarios fue diagnosticada de quilotórax espontáneo con extravasación de quilo a regiones cervical y mediastínica, en probable relación con sobreesfuerzo o traumatismo mínimo. Presentó una mejoría clínica y radiológica tras dieta exenta de grasas y administración de suplementos de triglicéridos de cadena media. Las causas más frecuentes de quilotórax son las intervenciones quirúrgicas, los traumatismos y las neoplasias. Además, se describen también casos de quilotórax espontáneo sin causa objetivable. Por último, en pacientes con derrame pleural y edema cervical hemos de tener en cuenta la posibilidad de una patología aguda del conducto torácico

Exudative pleural effusion has several etiologies, being the most frequent parapneumonic effusion, neoplasias and tuberculosis. We report a case of a 71-year-old woman with painful edema on the left side of the lateral cervical region, accompanied by increased soft tissues in that region in chest radiography and bilateral pleural effusion. After additional studies were conducted, she was diagnosed with spontaneous chylothorax with extravasation of chyleinto the cervical and mediastinal regions, possibly due to overexertion or minimal trauma. She underwent clinical and radiological improvement after a fat-free diet and the administration of medium chain triglycerides supplements. The most common causes of chylothorax are surgical procedures, trauma and cancer. In addition, cases of spontaneous chylothorax are also described without apparent cause. Finally, in patients with pleural effusion and cervical edema we must consider the possibility of an acute disorder of the thoracic duct

CHYLOTHORAX IN PARACOCCIDIOIDOMYCOSIS.

A previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions.

Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institution database.

OBJECTIVE: There is limited information regarding the true incidence of and risk factors for chylothorax after pediatric cardiac surgery. The objective of this study was to determine, from a large multi-institution database, incidence, associated factors, and treatment strategy in patients undergoing pediatric cardiac surgery. METHODS: All patients younger than 18 years in the Pediatric Health Information System (PHIS) database who underwent congenital heart surgery or heart transplant from 2004 to 2011 were included. Procedure complexity was assessed by Risk Adjustment for Congenital Heart Surgery-1. RESULTS: In all, 77,777 patients (55% male) of median age 6.7 months were included. Overall incidence of chylothorax was 2.8% (n = 2205), significantly associated with increased procedure complexity, younger age, genetic syndromes, vein thrombosis, and higher annual hospital volume. Patients with multiple congenital procedures had the highest incidence. Incidence increased with time, from 2% in 2004 to 3.7% in 2011 (P < .0001). Chylothorax was associated with longer stay (P < .0001), increased adjusted risk for in-hospital mortality (odds ratio, 2.13; 95% confidence interval, 1.75-2.61), and higher cost (P < .0001), regardless of procedure complexity. Of all patients with chylothorax, 196 (8.9%) underwent thoracic duct ligation or pleurodesis a median of 18 days after surgery. Total parenteral nutrition, medium-chain fatty acid supplementation, and octreotide were used in 56%, 1.7%, and 16% of patients, respectively. CONCLUSIONS: Chylothorax is a significant problem in pediatric cardiac surgery and is associated with increased mortality, cost, and length of stay. Strategies should be developed to improve prevention and treatment.

Quilotórax bilateral asociado a linfoma no Hodgkin, folicular: génesis del quilotórax / Bilateral chylothorax associated to non-hodgkin's follicular lymphoma: the origin of chylothorax

Varón de 50 años, con 7 meses de enfermedad caracterizada por mialgias, astenia, y malestar general. cinco meses antes de ingresar al Hospital Dos de Mayo (HNDM), desarrolla derrame pleural derecho que requiere drenaje pleural (1500-2500 cc/día). Internado en el HNDM se descubre un derrame pleural bilateral con incremento de triglicéridos. Una tomografía espiral multicorte (TEM), de tórax con contraste demostró adenopatías mediastinales, derrame pleural bilateral, liquido al interior de la pleura mediastinal derecha posterior adyacente a D10-D11-D12, e imagen osteolítica en cuerpo vertebral de D11. Una biopsia de ganglio axilar izquierdo, reveló un Linfoma no Hodgkin (LNH), folicular de células grandes y pequeñas. Estando sometido a una dieta alta en triglicéridos de cadena media y aceite de oliva como suplemento el paciente recibió quimioterapia (Dexametasona, Ciclofosfamida, Doxorrubicina, Vincristina), siendo dado de alta después del primer ciclo, con programación de quimioterapias cada 3 semanas y toracocentesis evacuatorias periódicas condicionales. Después de 5 meses de tratamiento, el quilotórax bilateral desapareció.

This is the story of a 50 year-old male subject with a 7-month illness characterized by myalgia, fatigue, and malaise. 5 months before being admitted to Dos de Mayo National Hospital (HNDM), he developed right pleural effusion requiring pleural drainage (1500-2500 mL/day).While in HNDM, the patient developed bilateral pleural effusion with increased triglycerides. A multiple-slice contrast spiral CT (TEM) of the chest showed mediastinal lymph node enlargement, bilateral pleural effusion, and the presence of fluid within the right posterior mediastinal pleura adjacent to D10-D11-D12, and an osteolytic image in D11 vertebral body. A left axillary lymph node biopsy revealed non-Hodgkin lymphoma (NHL), follicular type with large and small cells. The patient received a diet rich in medium-chain triglycerides and olive oilas a supplement, and he also received chemotherapy (dexamethasone, cyclophosphamide, doxorubicin, vincristine), being discharged after the first cycle. Chemotherapy was scheduled to be administered every 3 weeks, and drainage thoracentesis were also scheduled to be performed during his probation period. After 5 months of treatment, bilateral chylothorax disappeared.

[A case of chylothorax in which thoracoscopy under local anesthesia and thoracic duct scintigraphy were useful to locate the leakage site].

BACKGROUND: Detailed investigation of the cause of chylothorax and its treatment should be performed by thoracoscopy under general anesthesia, but if this is difficult due to multiple complications it is possible to perform a detailed investigation by combining thoracoscopy under local anesthesia and thoracic duct scintigraphy. CASE PRESENTATION: A 74-year-old woman presented with exertional dyspnea. Chest X-ray films showed right pleural effusion, and thoracocentesis yielded a milky white pleural effusion, meeting the criteria of chylothorax, after excluding conditions such as malignant lymphoma, amyloidosis and trauma. Since the patient's medical history included pacemaker insertion, dialysis and diabetes, thoracoscopy was performed under local anesthesia rather than general anesthesia, to investigate the cause in detail. The pleural cavity was visualized, but no obvious tumor or other cause was present in the parietal pleura. There was partial adhesion of the lower lobe and chest wall, and the leakage of a milky white pleural effusion from this site was confirmed. We then performed thoracic duct scintigraphy, which revealed an area of enhancement corresponding to the leakage site near the right pulmonary hilum. CONCLUSION: We describe a case in which thoracoscopy under local anesthesia and thoracic duct scintigraphy were useful for determining the leakage site in chylothorax.

[Influence of prolonged treatment with octreotide on GH, IGF I, insulin, ACTH, cortisol, T3, T4 and TSH secretion in a case of congenital chylothorax]. / Influenza del trattamento prolungato con octreotide sulla secrezione di GH, IGFI, insulina, ACTH, cortisolo, T3, T4 e TSH in un caso di chilotorace congenito.

Congenital chylothorax is a rare condition characterized by the accumulation of lymph fluid in the pleural space that causes respiratory and circulatory dysfunctions, immune deficiencies, hypoalbuminemia, electrolyte imbalance and alterations of the coagulation. Mortality rates are elevated and can rise to 50%. Therapy consists in conservative treatment based on thoracic drainage combined with total parenteral nutrition or use of low-fat high-protein diet supplemented with medium chain triglycerides. In case of failure surgical intervention may be considered. During the last years some authors have experienced the use of octreotide with doubtful results. In no case the drug impact on insulin, GH and cortisol secretion in neonatal age has been investigated and only in one case the effect on thyroid hormones has been assessed. We report the case of a 36-week baby with congenital chylothorax treated with octreotide for 42 days. The drug was well tolerated but hormonal level measurements showed a deep depression of insulin secretion unaccompanied by alterations of glucose levels. Levels of GH and TSH showed only a transitory decrease. ACTH and cortisol remained normal. At 5 months, the measurements of hormonal levels did not show significant alterations. It is not possible to determine if such a drug played an essential role in the solution of the pleural effusion, but it is important to emphasize that a prolonged treatment with octreotide has not caused, in our case, persistent hormonal alterations.

Severe venous and lymphatic obstruction after single-chamber pacemaker implantation in a patient with chest radiation therapy.

A 73-year-old woman with a history of paroxysmal atrial fibrillation, sinus node dysfunction, bilateral breast cancer, and extensive chest radiation developed progressive edema, dyspnea, and recurrent pleural effusions soon after single-chamber pacemaker implantation. Thoracentesis yielded a diagnosis of chylothorax, and progressive refractory anasarca developed. A computed tomography angiogram suggested obstruction of the superior vena cava and left subclavian vein despite outpatient therapeutic anticoagulation. Autopsy confirmed venous thrombosis, along with mediastinal fibrosis. The presumed etiology of the chylothorax and anasarca was obstruction of the atretic central venous structures following pacemaker implantation, critically impairing the already tenuous venous and lymphatic drainage. (PACE 2010; 520-524).

[Chylothorax]. / Le chylothorax.

PHYSIOLOGY: Chylothorax corresponds to the intrathoracic presence of chyle. Chyle is a lymph of intestinal origin containing the product of digested fat. This lymph joins the blood circulation through the thoracic duct. The thoracic duct receives a part of the lymphatic drainage from the viscera below the diaphragm, from the diaphragm and from the sterno-costal wall. PHYSIOPATHOLOGY: Intrapleural chyle issue is explained by an acquired or spontaneous lesion of the thoracic duct or of one of its collaterals in the thorax. The iatrogenic or spontaneous lesions of the collaterals suggest that the latter are incontinent and have lost their valve capacity, and hence provoke a reflux of chyle from the thoracic duct. The anatomy of the chylothorax (occasionally pathological) can be specified by a pedal lymphography. FROM A THERAPEUTIC POINT OF VIEW: Treatment, essentially medical, can be completed by surgery. The medical treatment is based on re-nutrition and a diet excluding fat, supplemented by medium chain triglycerides. Surgery consists in pleural symphysis and/or suture of the damaged collaterals, or ligature of the thoracic duct. The indications depend on the severity of the chyle leakage and the type of original lesion. The indications therefore depend on the etiology and clinical evolution of each case. These different treatments, isolated or combined, lead to the regression of the effusion in nearly all cases.

Octreotide in the treatment of thoracic duct injuries.

Anecdotal reports support the use of octreotide in the treatment of traumatic thoracic duct injuries and chylothorax, but no prospective studies have proved its efficacy. We evaluated the effects of octreotide in treating thoracic duct transection in a canine model. Eight mongrel dogs (27.8+/-5.1 kg) were fed one pint of 10.5 per cent milkfat 2 hours before operation. Through a left supraclavicular neck incision, the thoracic duct was identified and transected, producing free flow of chyle. A quarter-inch drain was tunneled subcutaneously from the wound and attached to closed suction. After wound closure dogs were randomized to a control group (n = 4) receiving sham injections of saline subcutaneously three times per day, or a treatment group (n = 4) given 3 microg/kg octreotide three times per day. Postoperatively all dogs were fed a standard low-fat (5-7%) crude fat diet. Drain output was measured each day, and on odd-numbered postoperative days the drainage was analyzed for cholesterol, triglycerides, albumin, and total protein. Fistula closure was defined as drainage <10 ml/24-hour period. Treated dogs achieved fistula closure significantly faster than controls: 3.5+/-1.3 days versus 7.8+/-1.0 days (P = 0.0037). Whereas equivalent amounts of drainage occurred on the day of surgery and on postoperative day one in both groups, by postoperative day 2 the treatment group had significantly less drainage over 24 hours: 63+/-69 ml versus 195+/-79 ml (P = 0.046); this significant difference persisted through postoperative day 5 when drainage began to decrease in the control group. No significant differences between groups were seen in levels of cholesterol, triglycerides, albumin, or protein in the drainage at any time point. We conclude that octreotide is effective in treating thoracic duct injury, leading to an early decrease in drainage and early fistula closure. The mechanism for this effect remains to be clarified.

Chylothorax: therapeutic alternatives.

Persistent loss of chyle, rich in metabolites, water and electrolytes, can be quickly devastating, particularly in debilitated patients and children. Chylothorax of traumatic origin, especially when loss of chyle is rapid, is most effectively arrested with direct closure of the fistula or ligation of the thoracic duct. Thoracic duct ligation is indicated when a controlled fat diet or parenteral hyperalimentation without oral intake and closed chest drainage are not effective in arresting chylous pleural effusions.