Chylothorax and Chylous ascites: the same aetiology for two different conditions

Abstract

Chylous pleural effusions result from disruption/obstruction of the thoracic duct1. Chylous ascites is due to an interruption in the lymphatic system2. Simultaneous accumulation of chyle in multiple cavities, in non-traumatic etiologies, is rare3. A 90-year-old man was admitted in the emergency department complaining of progressive breathlessness, dry cough, asthenia and abdominal distension over the last 8 days. He denied fever, anorexia and weight loss. He was no past of smoking habits and his past medical history was not relevant, besides history of hypertension. General physical examination showed a pale male, emaciated, with breath sounds absent in left basal area with stony dull percution note. Per abdomen, shifting dullness was present. Routine blood investigations revealed macrocytic anemia, elevation on C-reactive protein of 3,56 mg/dL (normal value < 0,5mg/dL), erythrocyte sedimentation rate of 105 mm (normal value < 15 mm), creatinine of 2,02 mg/dL (normal value 0,6-1,20 mg/dL). The chest radiograph was suggestive of left pleural effusion. Thoracocentesis and paracentesis were performed with drainage of milky fluid. Pleural fluid examination revealed: >1000 cells/mm3, mostly lymphocytes, glucose 71,9 mg/dL, protein 3 g/dL, triglyceride 506 mg/dL, cholesterol 45 mg/dL, adenosine deaminase 17,2 UI/L. Peritoneal fluid was also examinated: >1000 cells/mm3, mostly lymphocytes, glucose 69,2 mg/dL, protein 3,2 g/dL, triglyceride 489 mg/dL, cholesterol 48 mg/dL, ADA 8,9 UI/L. Serum triglyceride and cholesterol were 122 mg/dL and 106 mg/dL, respectively. Pleural and peritoneal fluid analysis did not reveal any abnormal cell and cultures were sterile, including culture for Mycobacterium tuberculosis. A chest computed tomography showed a large solid, nodular mass surrounding the aorta, with 14x11 cm. Flow cytometry revealed non-Hodgkin lymphoma. Our patient was treated conservatively with corticosteroid and a diet of medium chain triglyceride oil, with progressive deterioration of clinical status with unfavorable evolution. Lymphomas are one of the main non-traumatic causes of chylothorax and chylous ascites (70% of cases, mostly non-Hodgkin lymphoma)4,5 and may be the first manifestation of the disease. Patients with leaks from retroperitoneal lymphatics may present as isolated chylothorax or combined with chylous ascites4. Treatment is the same as that of the hematologic malignancy. A pleural/ascitic fluid triglyceride level greater than 110 mg/dL is an accurate marker for the presence of chylothorax/chylous ascites1,3.