SESSION TITLE: Pleural Student/Resident Case Report Posters
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Spontaneous chylothorax is a rare cause of pleural effusions outside of the neonatal period. A case of traumatic chylothorax and spinal contusion in a toddler is described without any overt signs of injury.
CASE PRESENTATION: A healthy fifteen month female presented to the emergency room with inability to bear weight. Earlier that day, she played in a bounce house and upon returning home she could not ambulate. Two days prior, patient had a fever of 39 oC, rhinorrhea, and productive cough. She also had a coughing spell while eating dry cereal. Mom’s boyfriend was recently incarcerated. On examination, she was febrile to 38.5oC and tachypneic, without any signs of trauma or neurologic deficits. Chest xray revealed opacification of the right hemithorax. WBC was 8.1 x103/mcL with a normal differential, CRP was 1.5mg/dL and albumin was 3.0gm/dL. Quantiferon level and PPD were negative. Shortly after admission, patient became hypoxic. Bronchoscopy was negative. An ultrasound visualized large unloculated pleural effusion. Chest tube output was milky and fluid analysis revealed triglycerides of 675 mg/dL, nucleated cell count of 39,090/mcL with 94% lymphocytes, consistent with chylothorax. She received TPN. With continued chyle output, an octreotide drip was started without success. Patient underwent thoracic duct ligation. Right lung biopsy was negative. Concurrently, she had acute deterioration of her bilateral lower extremity paresis. MRI detected a focal intramedullary cord lesion with surrounding soft tissue enhancement without any cord compression. A biopsy of that tissue and CSF sampling revealed no signs of malignancy or infection. Patient received rehabilitation therapy and then discharged home on a fat free diet.
DISCUSSION: Chylothorax can be associated with malignancy, trauma, surgery, sarcoidosis, infections, congestive heart failure, deep vein thrombosis and idiopathic. Once we diagnosed chylothorax, we first evaluated for infections including tuberculosis. Patient did not have any previous surgeries. A lung biopsy ruled out sarcoidosis, lymphangiomatosis or malignancies. Imaging showed the thoracic duct did not have any obvious compression. Non-accidental trauma was also investigated through social services. Thus, occult trauma was a diagnosis of exclusion. A posterior thoracic injury can explain the severed thoracic duct and spinal contusion. Adult literature has cited reports of thoracic duct lesions after car accidents, but no reports are noted in children.
CONCLUSIONS: Traumatic chylothorax should be considered in pediatric populations despite lack of overt physical abnormalities. Adequate evaluation of other causes should be pursued.
Reference #1: Soto-Martinez M, Massie J. Chylothorax: Diagnosis and Management in Children. Paediatric Respiratory Reviews. 2009 Dec; 10 (4):199-207.
Reference #2: Büttiker V1, Fanconi S, Burger R. Chylothorax in children: guidelines for diagnosis and management. Chest. 1999 Sep;116(3):682-687.
DISCLOSURE: The following authors have nothing to disclose: Kelly Welker, Shimoni Dharia
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