SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Chylothorax is an uncommon cause of pleural effusion. It is due to the abnormal drainage of chyle, a product of long chain triglycerides (LCT); into the pleural cavity.1 Damage of the thoracic duct results in chylothorax.1 Lymphoma is the most common cause of non-traumatic chylothorax.2 It has a high recurrence rate using chest tube pleurodesis. We present a case of successful chest tube pleurodesis with the use of TPN and octreotide, thought to decrease lymphatic flow. Optimal management is unclear given the lack of randomized controlled trials. Conservative management begins with medium chain triglycerides (MCT) which is directly absorbed in the portal venous system, but this rarely succeeds.2 TPN, which limits LCT intake, can be used alone or with MCT but only has a 20-80% success rate.2 Octreotide may be used as an adjunct though data is limited.2
CASE PRESENTATION: A 49 year old male with stage IV DLBCL s/p RCHOP presented with dyspnea and orthopnea. Imaging showed large bilateral pleural effusions with diffuse thoracic lymphadenopathy. He underwent bilateral thoracentesis which revealed a lymphocytic-predominant exudative effusion with high triglycerides and DLBCL was confirmed on flow cytometry. He was treated with RICE (chemotherapy) and discharged. One week later, he represented with similar symptoms. Imaging showed worsening large bilateral pleural effusions. He was started on TPN and octreotide, followed by therapeutic thoracentesis and bilateral chest tube pleurodesis with talc. His symptoms resolved and he was discharged home on a MCT diet.
DISCUSSION: Non-traumatic chylorax due to malignancy is difficult to manage and has a higher recurrence rate than surgical chylothorax.3 Chemoradiation has a 0-33% success rate.2 In one small retrospective study, the majority of those with non-traumatic chylothorax failed the conservative approach.3 And of those that failed and underwent surgical intervention, 30% had a recurrence.3 TPN and octreotide were initiated prior to pleurodesis to help reduce lymphatic flow and to potentially increase success of pleural sclerosis.
CONCLUSIONS: In view of our findings, it is reasonable to consider using TPN and octreotide in all patients undergoing chest tube pleurodesis for refractory non-traumatic chylothoraces, as this combination may provide greater efficacy than either therapy alone.
Reference #1: Doerr CH, Miller DL, Ryu JH. Chylothorax. Semin Respir Crit Care Med. 2001;22(6):617-26.
Reference #2: Schild H, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013;110 (48):819-26.
Reference #3: Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH. Medical Management of chylothorax and associated outcomes. Am J Med Sci. 2010;339(4):314-8.
DISCLOSURE: The following authors have nothing to disclose: Marc Lorenz Montecillo, Nader Kamangar
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