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Correspondence |

Pseudochylothorax, an Unknown Disease FREE TO VIEW

Alberto Garcia-Zamalloa, MD
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From the Service of Internal Medicine, Western Gipuzkoa Clinical Research Unit, Hospital of Mendaro.

Correspondence to: Alberto Garcia-Zamalloa, MD, Service of Internal Medicine, Western Gipuzkoa Clinical Research Unit, Hospital of Mendaro, 20850 Gipuzkoa, Spain; e-mail: Alberto.Garcia-Zamalloazamalloa@osakidetza.net


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(4):1004-1005. doi:10.1378/chest.09-2628
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To the Editor:

I congratulate Dr. Wrightson and colleagues on the excellent paper recently published in CHEST (October 2009)1 about their experience with six cases of arthritis-associated pseudochylothorax without pleural thickening and short duration of symptoms. I absolutely agree with them: The pathogenesis of pseudochylothorax has not been clarified yet. The very low incidence (around 190 cases reported) of this probably underdiagnosed disease has historically constituted, in my opinion, the major obstacle for the performance of randomized trials and the availability of clinical and research resources.

The authors state that “the medical literature has always emphasized that a hallmark of pseudochylothoraces is the presence of a grossly thickened (fibrotic) pleura … [and] that a pleural inflammatory process of at least 5 years is required for its development.” Presently, almost all our knowledge about pseudochylothorax comes from case reports and retrospective descriptive reviews, so that definitive statements should be difficult to make. In our review of 174 cases published until 1999,2 we found a “remarkable association of pseudochylothorax with long-term effusions,” but we also pointed out that 16 patients (9%) had a pleural effusion of < 5 years of evolution, one of them of 4 months, due to echinococciasis, as had already been reported in 1975.3

Pleura on pseudochylothorax presents most frequently as chronic inflammation and/or fibrous tissue, as revealed by performed biopsies, and seems to have a low yield for etiologic diagnosis (17% in tuberculous and 15% in nontuberculous cases in our review).2 On the other hand, as the authors comment, Hamm et al4 demonstrated a peak in the high-density lipoprotein region and a lack of low-density lipoprotein cholesterol in pseudochylous fluid. They theorized that trapped cholesterol changed its lipoprotein-binding characteristics, possibly due to local metabolism, but could not rule out other mechanisms, so the precise pathogenic mechanism of cholesterol accumulation in pseudochylothorax remains unknown.

I find of great interest the experience of the authors on controlling or even diminishing the pleural fluid volume with disease-modifying antirheumatic drugs. In our experience, even successful treatment of an acute tuberculous pleurisy did not preclude the eventual development of pseudochylothorax, and we recommended to follow up closely residual effusions after appropriate treatment.2 As a final comment, it is in my opinion highly likely that TB will unfortunately remain the leading cause for pseudochylothorax during the next decades, due to the current high incidence of TB and the increasing problem of drug resistance,5 which could decrease the effectiveness of the antituberculous treatment.

Wrightson JM, Stanton AE, Maskell NA, Davies RJ, Lee YC. Pseudochylothorax without pleural thickening: time to reconsider pathogenesis? Chest. 2009;1364:1144-1147. [CrossRef] [PubMed]
 
Garcia-Zamalloa A, Ruiz-Irastorza G, Aguayo FJ, Gurrutxaga N. Pseudochylothorax. Report of 2 cases and review of the literature. Medicine (Baltimore). 1999;783:200-207. [CrossRef] [PubMed]
 
Carel RS, Schey G, Bruderman I. Chyliform pleural effusion. An unusual manifestation of hepatothoracic echinococcus cysts. Chest. 1975;684:598-599. [CrossRef] [PubMed]
 
Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration. 1991;585-6:294-300. [CrossRef] [PubMed]
 
Donald PR, van Helden PD. The global burden of tuberculosis—combating drug resistance in difficult times. N Engl J Med. 2009;36023:2393-2395. [CrossRef] [PubMed]
 

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References

Wrightson JM, Stanton AE, Maskell NA, Davies RJ, Lee YC. Pseudochylothorax without pleural thickening: time to reconsider pathogenesis? Chest. 2009;1364:1144-1147. [CrossRef] [PubMed]
 
Garcia-Zamalloa A, Ruiz-Irastorza G, Aguayo FJ, Gurrutxaga N. Pseudochylothorax. Report of 2 cases and review of the literature. Medicine (Baltimore). 1999;783:200-207. [CrossRef] [PubMed]
 
Carel RS, Schey G, Bruderman I. Chyliform pleural effusion. An unusual manifestation of hepatothoracic echinococcus cysts. Chest. 1975;684:598-599. [CrossRef] [PubMed]
 
Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration. 1991;585-6:294-300. [CrossRef] [PubMed]
 
Donald PR, van Helden PD. The global burden of tuberculosis—combating drug resistance in difficult times. N Engl J Med. 2009;36023:2393-2395. [CrossRef] [PubMed]
 
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