Chylothorax in thyroid surgery: a very rare case and systematic review of the literature.

BACKGROUND: Chylothorax is a very rare but major complication in thyroid surgery and should be apparent to clinicians in this field. CASE PRESENTATION: We report a case with chylothrax after thyroid surgery in our department that drew our attention. METHODS: Systematic review of the literature to evaluate the incidence and the contributing factors of chylothorax after thyroid surgery. Database (PubMed) and hand searches to identify patients with thyroid surgery and postoperative chylothorax. Keywords included chylothorax, thyroidectomy, thyroid surgery and complications. Two independent reviewers screened studies against inclusion and exclusion criteria. Patient characteristics, risk factors, symptoms, treatments and etiopathogenesis were investigated. RESULTS: We identified 13 articles in the literature describing 19 patients with chylothorax after thyroidectomy and described our own case. Ninety percent of the patients underwent thyroidectomy for thyroid cancer. Sixteen patients (80 %) underwent thyroidectomy with at least a left lateral neck dissection, 2 patients (10 %) underwent thyroidectomy with sternotomy, and in the remaining 2 patients (10 %), thyroidectomy with lateral neck dissection on both sides was performed with partial sternotomy. Our calculated incidence for chylothorax with total thyroidectomy and neck dissection was 1.85 %; for a thoracic approach the calculated incidence was 7.3 %. CONCLUSIONS: There are no reports of chylothorax after thyroidectomy without at least a left lateral neck dissection due to advanced thyroid cancer and/or sternotomy due to the thyroid size. The extension of thyroid surgery seems to be the main risk factor in developing chylothorax either through direct surgical trauma or through increased intraductal pressure after thoracic duct ligation. An early diagnosis of chylothorax may avoid severe metabolic or cardiopulmonary complications.

Foodborne outbreaks, Austria 2007.

In 2007 Austria reported a total of 438 foodborne outbreaks affecting 1715 people, including 286 hospitalized patients and one death. Salmonella spp. and Campylobacter spp. accounted for 95% of all reported outbreaks. Forty-eight (11%) of the 438 Austrian outbreaks were acquired abroad. Of the 390 domestically acquired foodborne outbreaks, bacterial infection caused 376, viruses (norovirus and 1-time hepatitis A virus) caused 11, and intoxications (Staphylococcus aureus enterotoxins, alkaloid toxins) caused two. In one outbreak the causative agent was unknown. Salmonella spp. caused 264 (70%) of the bacterial outbreaks, Campylobacter spp. caused 104 (28%), enterohemorrhagic Escherichia coli (EHEC O145:H-, O157:H-, O157:H7, O182: H49, O91:H7, ONT:H4) caused six, Shigella flexneri and Shigella sonnei each caused two. The hospitalization rates were 22% for domestically acquired infections with Salmonella spp. and 14% for Campylobacter spp. Among outbreaks where the source was known, eggs were implicated in 49%, meat products (especially poultry) in 44% and fish in 2%. The ratio of household outbreaks to general outbreaks was 82.3% to 17.7%. In 54 of the 62 general domestic outbreaks the following locations of exposure were documented: commercial food suppliers (e.g. restaurants, cafeterias) 24 times, family celebrations, nursery schools, take-aways and barbecues 22 times, nursing homes and hospitals eight times. It is likely that the relatively high number of household outbreaks reflects an insufficient level of epidemiological investigation of outbreaks in Austria. More resources may be needed for identification of individual clusters that belong to larger foodborne outbreaks exceeding district or provincial borders.

A foodborne outbreak of Salmonella Enteritidis phage type 6 in Austria, 2008.

In April 2008, a general foodborne outbreak of Salmonella Enteritidis phage type 6 affected nine persons (two households in Salzburg and one household in Tyrol; eight microbiologically confirmed cases and one possible case). Epidemiological investigation revealed that all cases had eaten lunch together at a farm. Homemade bread dumpling loaf, prepared with eggs from the farm, was the most likely vehicle for the pathogen. Six eggs were bacteriologically tested and yielded the outbreak strain on the egg shells. The farm's egg laying flock consisted of 12 hens, which were identified as the source of infection by isolating the outbreak strain from samples of hen fecal material and dust. Molecular subtyping using multiple loci variable number of tandem repeats analysis (MLVA) revealed a pattern unique to isolates from the outbreak, different from nine epidemiologically unrelated isolates tested for comparison. The laying hens were culled and no further cases of salmonellosis were associated with the farm. This example demonstrates the considerable potential of outbreak investigation to elucidate the transmission of infection along the food chain and to provide information essential for implementation of targeted measures for prevention of foodborne illness.

An outbreak of febrile gastroenteritis associated with jellied pork contaminated with Listeria monocytogenes.

In September 2008, the Austrian Agency for Health and Food Safety (AGES) learned of an outbreak of diarrheal illness that included a 71-year-old patient hospitalized for gastroenteritis with a blood culture positive for Listeria monocytogenes. Three stool specimens provided by seven of 19 persons attending a day trip to a foreign city, including a final break at an Austrian tavern, yielded L. monocytogenes. All isolates were of serovar 4b and had fingerprints indistinguishable from each other. A cohort study revealed that the outbreak of gastroenteritis occurred among 16 persons who had eaten dinner at the wine tavern on September 6. Of the 15 persons who ate from platters of mixed cold-cuts, 12 (80%) developed symptoms of febrile gastroenteritis within 24-48 h. The median age of those who became ill was 62 years. A 72-year-old patient recovered from gastroenteritis but was hospitalized with bacterial meningitis on day 19 after the dinner. The epidemiological investigation identified the consumption of mixed cold-cuts (including jellied pork) at the wine tavern as the most likely vehicle of the foodborne outbreak (P = 0.0015). This hypothesis was confirmed by microbiological investigation of jellied pork produced by the tavern owner on September 3. L. monocytogenes was isolated from leftover food in numbers of 3 x 10(3)-3 x 10(4) colony forming units/g and was indistinguishable from the clinical outbreak isolates. Symptoms reported by the 12 patients included unspecified fever (12x), diarrhea (9x), headache (5x), vomiting (4x), body aches (2x) and sore throat (1x). Active case finding identified one case of rhombencephalitis (female, age 48) among another group of four guests, among whom only the patient and her asymptomatic husband had eaten jellied pork on September 6. This is the first outbreak of L. monocytogenes-associated gastroenteritis reported in Austria. The occurrence of a secondary case of meningitis (diagnosed on day 19 after consumption of jellied pork) indicates a significant risk of systemic listeriosis among elderly patients with febrile gastroenteritis caused by L. monocytogenes; antibiotic therapy should therefore be considered in such cases of documented listerial gastroenteritis.

[Food borne infectious outbreaks, Austria 2005]. / Lebensmittelbedingte infektiöse Krankheitsausbrüche, Osterreich 2005.

In Austria, a total of 606 food borne outbreaks, affecting 1,910 people altogether (including 368 hospitalized patients and 1 fatal outcome) were documented in 2005. Salmonella spp. and Campylobacter spp. accounted for 99% of all reported outbreaks. Fortysix (8%) of the 606 outbreaks were acquired abroad. Bacteria caused all but one of the 560 domestically acquired food borne outbreaks: 427 (76%) were due to Salmonella spp., 128 (23%) due to Campylobacter spp. and two outbreaks each due to enterohaemorrhagic Escherichia coli and Yersinia enterocolitica. Norovirus caused an outbreak affecting 22 persons. The respective hospitalization rate for domestically acquired Salmonella spp. and Campylobacter spp. infections was 20% and 16%. Of those outbreaks where information as to the source was provided, eggs were implicated in 57%, meat products (especially poultry) in 30% and milk or dairy products (especially raw milk) in 4%. The ratio between family outbreaks and general outbreaks was 89% to 11%. For general outbreaks the following locations of exposure were given: commercial food suppliers (incl. restaurants, cafeterias) 34 x, family celebrations 14 x, nursery schools 4 x, festivities (e.g. fairs) 3 x, nursing homes twice and once a mixed outbreak involving commercial food suppliers plus homes (Austria-wide S. Enteritidis PT19 outbreak). In our opinion, the relatively high number of family outbreaks merely reflects the still insufficient quality of epidemiological outbreak investigation in Austria, i.e. lack of consolidating individual clusters into larger food borne outbreaks which exceed district or provincial borders.