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John M. Wrightson, MA; Andrew E. Stanton, MD; Nicholas A. Maskell, DM; Robert J. O. Davies, DM; Y. C. Gary Lee, PhD, FCCP
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From the Oxford Pleural Unit (Drs Wrightson, Stanton, and Davies), Oxford Centre for Respiratory Medicine, Churchill Hospital; North Bristol Lung Centre (Dr Maskell), Bristol University; National Institute for Health Research Oxford Biomedical Research Centre (Drs Wrightson and Davies); and School of Medicine and Pharmacology and Centre for Respiratory Research (Dr Lee), University of Western Australia and Sir Charles Gairdner Hospital.

Correspondence to: John M. Wrightson, MA, Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, OX3 7LJ, England; e-mail: johnwrightson@thorax.org.uk


Financial/nonfinancial disclosures: The authors have 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 (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(4):1023-1024. doi:10.1378/chest.10-1350
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To the Editor:

We thank Drs Cansever and Bedirhan for their suggestion that video-assisted thoracoscopic surgery (VATS) is not necessary for patients with pseudochylothorax. Our case series discussed six patients with arthritis-associated pseudochylothorax who were particularly notable because of their minimal pleural thickening. These findings were in striking contrast to the previously held belief that gross pleural thickening is a prerequisite for pseudochyle formation.1

Of the six patients discussed, three had a thoracoscopy primarily to obtain biopsy specimens for exclusion of TB and malignancy. It is worth highlighting that physicians performed the pleuroscopies (local anesthetic thoracoscopies) under conscious sedation. None of our patients had general anesthetic VATS, and a decortication was not required (given the minimal pleural thickening).

We entirely agree that neither pleuroscopy nor VATS is necessarily mandated for diagnostic purposes in patients with unequivocal pseudochylothorax with a clear etiology, such as rheumatoid arthritis. Unfortunately, the clinical scenario frequently is not so clear cut particularly because TB causes the majority (54%) of pseudochylothoraces worldwide.2 Physicians therefore should always consider alternative diagnoses, such as TB, particularly in patients who are relatively immunosuppressed due to treatment of rheumatoid arthritis. Where there is any diagnostic doubt, an outpatient pleuroscopy is a one-stop procedure to obtain pleural biopsy specimens and achieve pleural volume control. However, one particular question remains: How often do pleural biopsy specimens add diagnostically useful information in cases with grossly thickened pleura vs those with relatively normal pleura? It is conceivable that biopsy specimens from intensely thickened pleura are less likely to be helpful, potentially yielding fibrous tissue rather than findings characteristic of a specific underlying disease.

Wrightson JM, Stanton AE, Maskell NA, Davies RJO, Lee YCG. 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]
 

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Wrightson JM, Stanton AE, Maskell NA, Davies RJO, Lee YCG. 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]
 
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