Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I |

Spontaneous Bilateral Chylothorax With Fatal Outcome in a Patient With Cryptogenic Cirrhosis: A Rare Occurence FREE TO VIEW

Sabeeda Kadavath, MD; Daniel Sittler, MD; Hussein Assallum, MD; Elie Hatem, MD
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Lincoln Medical and Mental Health Center, Bronx, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1072A. doi:10.1016/j.chest.2016.08.1179
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Chylothorax is a relatively rare condition characterized by pleural fluids with a high concentration of fatty acids. Bilateral chylothorax is an even more unusual presentation. Although cryptogenic cirrhosis has been described as a possible etiology in literature, no case report has been described. Here we describe a case of bilateral chylothorax non traumatic in etiology secondary to cryptogenic cirrhosis.

CASE PRESENTATION: 67yo female presented to a suburban hospital with increased shortness of breath and decreased exercise tolerance for four months that acutely worsened over one day. She also reported cough, chest tightness and wheezing. Past medical history was significant for Asthma, GERD, HTN and Cryptogenic cirrhosis. On presentation to the ER, patient was found in distress, BP180s/80s, HR150/min, fever, Sat 90% on 100% NRBM. No Breath sounds were noted on the right and needle decompression done on field showed no return of air. Upon arrival to the ED, CXR showed bilateral patchy densities and bilateral pleural effusion. Our initial impression was heart failure exacerbation or pneumonia. No improvement was noted with initial diuresis.2D ECHO did not report any abnormality. She was managed for severe ARDS secondary to aspiration pneumonia requiring intubation. On thoracocentesis, labs showed transudative bilateral pleural effusions pH of 7.5, cloudy, white and lymph concentration of 46% , milky in color with triglyceride level of 410.Flow cytometry showed no lymphocytic evidence of a lymphoproliferative disorder. HCV and HBV negative, HIV Ab negative, HHV-8 PCR negative. Pleural fluid and blood cultures were serially negative. Cirrhosis was present in the absence of a history of alcohol use, negative serology, negative alpha-1 antitrypsin and no fatty infiltration on imaging. Her condition complicated further with the refractory shock and multiorgan failure. Patient eventually died from pulseless electrical activity with no return of circulation on cardiopulmonary resuscitation. Autopsy was discussed to ascertain cause of death but was refused by family.

DISCUSSION: Trauma and tumor are responsible for the majority of the cases of bilateral chylothorax that we were able to find in a search of related literature. One paper from the Mayo Clinic described cryptogenic cirrhosis as an etiology for chylothorax in the presence of chylous ascites (1).However we could not find any case report describing bilateral chylothorax in the setting of cryptogenic cirrhosis and in the absence of chylous ascites. Ours would be the first case to report the same.

CONCLUSIONS: In conclusion, cryptogenic cirrhosis is a rare cause of bilateral chylothorax .In a patient with dyspnea, chest pain or decreased exercise tolerance in the setting of cryptogenic cirrhosis, the diagnosis of spontaneous chylothorax should be given due consideration.

Reference #1: Etiology of Chylothorax in 203 Patients. Doerr, Clinton H. et al. Mayo Clinic Proceedings, Volume 80, Issue 7, 867-870

DISCLOSURE: The following authors have nothing to disclose: Sabeeda Kadavath, Daniel Sittler, Hussein Assallum, Elie Hatem

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