INTRODUCTION:Contarini’s syndrome describes simultaneous pleural effusions of different appearance and etiology (1). Our patient presented with chylous and serous effusions. Chylothorax is caused by thoracic duct leakage, common causes of this are malignancy mainly lymphomas and lung CA and trauma. Rare causes are other malignancies, yellow nail syndrome, lymphangioleimyomatosis, cirrhosis, tuberculosis (TB) and filiariasis.
CASE PRESENTATION:The patient was a 46-year -old woman who presented with increasing dyspnea over the past week. She denied chest pain, fever, chills and cough. She was diagnosed with ovarian carcinoma 5 years before but only agreed for chemotherapy 1 year ago. She had omental metastasis on admission. She denied any history of (h/o) trauma; she did not have any ports for chemotherapy or central lines. Her last chemotherapy was 3 months prior. Social History: she was a lifetime non-smoker and had no h/o of foreign travel or no h/o TB. Physical examination showed a cachetic woman in mild respiratory distress. Temperature 97, Respiratory rate 26, Blood pressure 110/60, Heart rate 110. HEENT-temporal wasting; Neck-supple; Left lung-dullness on percussion about 2/3 hemithorax without breath sound, Right lung- good air movement in upper zone, mild decreased at base; CV-S1S2 tachycardia; Abdomen-firm, non-tender, normal bowel sounds; Extremities-no edema. Laboratory- WBC 22.9, H/H 11.9/36.5, Platelets 687, INR-4.97, PTT-64.4, AST-91, ALT-116, AP-717, CA 125-297, BNP-320, Protein-5, albumin-2.0. CXR on admission showed mild cardiomegaly, moderate left sided effusion and small right effusion. CXR post thoracentesis showed no masses and bilateral small effusions. CT abd/pelvis on admission showed abdominal and pelvic ascites, normal liver, mildly distended gallbladder and thickening of the anterior omentum. CT chest 7 months prior was normal. Thoracentesis had 3 liters of milky white effusion, glucose-111, triglycerides-231, protein-3.1, LDH 89, Specific gravity-1.010, pH-7.401, cell block showed rare inflammatory cell that was negative for malignancy. After diagnostic and therapeutic thoracentesis (Chest tube placed for 2 days) patient’s SOB resolved. In hospital, she had an increase in the right pleural effusion and thoracentesis was performed on this side, 10 days after admission. Thoracentesis had 1.5 liters of serous effusion, chemistry was not obtained, cytology showed cohesive clusters of markedly atypical cells highly suspicious for malignancy.
DISCUSSIONS:This patient presented with Contarini’s syndrome: she had a left chylous effusion and a right serous effusion. Lawton and colleagues reported a similar case in 1985, which was caused by ovarian carcinoma (2). Two processes were occurring: 1. Obstruction of the thoracic ducts in the left hemithorax secondary to metastatic lesions and 2. Metastatic ovarian carcinoma to the pleural causing serous effusion. Chemical analysis was not done on the right effusion. A fasting patient may have serous-appearing effusion that is actually chylous. Our patient was not fasting she was on the same diet in hospital and before admission. It is also unlikely that her nutritional status caused one hemithorax to have a milky color fluid and other serous fluid. Since both effusions presented at the same time.
CONCLUSION:This is the second reported case of Contarini’s syndrome due to ovarian carcinoma. One should not assume that bilateral pleural effusions are of the same appearance and etiology.
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