Abstract Introduction Chylothorax is a rare cause of pleural effusion and has a 90-day mortality rate up to 82%. In children, congenital abnormalities represent the most common etiology of chylothorax. Chylothorax is treated by thoracic duct ligation or thoracic duct embolization, which is favored due to its minimally invasive approach and more favorable success rates. Recurrence of chylothorax after treatment is uncommon and often challenging to manage. We report a case of recurrent bilateral chylothoraces in a healthy young male who had thoracic duct embolization in childhood. Case A 23-year-old man presented with three days of progressive dyspnea, pleuritic chest discomfort and pink-tinged sputum. The patient reported having a pericardial effusion requiring a pericardial window and lymphangiography at age 11, but he was unable to report the cause of the pericardial effusion or indication for lymphangiography. Review of patients prior imaging showed metallic mediastinal coils, consistent with previous thoracic duct embolization. On admission, vital signs were normal. Laboratory evaluation was notable for an elevated D-dimer (8,040 ng/mL). Chest radiograph showed moderate bilateral effusions, and CT angiography revealed large bilateral pleural effusions without pulmonary embolism and a small pericardial effusion (Figure 1a). Right-sided thoracentesis drained 2L of milky fluid (Figure 1b). Pleural studies revealed lymphocyte-predominant fluid (WBC 2,515/mm3; 81% lymphocytes), protein 3.8 g/dL, LDH 122 U/L, normal glucose and pH, and triglycerides 2,015 mg/dL, confirming chylothorax. Subsequent left sided thoracentesis removed an additional 2L of fluid. Cultures returned with no growth of organisms, and cytology was negative for malignant cells. Patient underwent robotic-assisted thoracic duct ligation with bilateral chest tube placement and talc pleurodesis. He had no recurrence of chylothorax and was discharged to home. Patient continues to take octreotide and interval imaging shows no recurrent effusions. Discussion Chylothorax may recur even years following thoracic duct embolization. Therefore, patients with treated chylothorax should be monitored longitudinally, although the best method for surveillance is undetermined. Prompt recognition of recurrent chylothorax is essential to avoid complications from prolonged chyle loss. Definitive management of recurrent chylothorax requires multidisciplinary review and may include thoracic duct ligation in cases of embolization failure. This abstract is funded by: None
Margolskee et al. (Fri,) studied this question.