Nontraumatic Chylothorax in the Setting of Superior Vena Cava Stenosis

Introduction

Chylothorax is a rare but potentially morbid complication following thoracic surgery. Nontraumatic chylothorax is even less common and typically is due to malignancy, congenital or idiopathic disorders of the lymphatic system, systemic diseases, and infection [1]. Here, the authors present a case of nontraumatic chylothorax due to central venous stenosis.

Case Presentation

A 57-year-old man with a history of renal failure and previous renal transplantation complicated by rejection requiring dialysis presented to the emergency room with the acute onset of dyspnea, nonproductive cough, and an inability to lay flat. He had a history of prior left tunneled internal jugular dialysis catheter placement and left upper extremity dialysis fistula, which had previously required multiple fistulagrams for prolonged bleeding and elevated venous pressures. During examination, his chest x-ray showed a large left pleural effusion and he underwent thoracentesis by the emergency medicine team with evacuation of 2 L of turbid fluid.

Given his chronic immunosuppression, he was admitted by internal medicine for initiation of intravenous (IV) antibiotics. Thoracic surgery, transplant infectious disease, and nephrology were consulted following admission. He underwent an echocardiogram, which did not demonstrate congestive heart failure. A computed tomography (CT) scan demonstrated right internal jugular occlusion, superior vena cava (SVC) stenosis, prominent thoracic venous collaterals, and cervical and mediastinal lymphadenopathy (Figures 1 and 2). His pleural fluid cytology and cultures were negative, but testing indicated the presence of chylomicrons and his triglyceride level was 1154 mg/dL, which was consistent with a chylothorax.

His IV antibiotics were discontinued, and he was placed on a medium chain triglyceride diet with octreotide three times daily. A cervical lymph node biopsy was negative for lymphoma, and he was monitored closely as an outpatient for recurrence. He continued to reaccumulate chylous fluid despite dietary modifications and required additional thoracenteses.

Subsequently, the decision was made to proceed with a venogram and possible SVC stent placement. If this were unsuccessful, he would undergo thoracoscopic thoracic duct ligation. He was found to have hemodynamically significant stenosis of the superior SVC resulting in a 21 mm Hg pressure gradient between the left innominate vein and central SVC. He underwent successful stent placement with decompression of previously visualized left thoracic venous collaterals (Figure 3). After stent placement the pressure gradient was reduced to 1 mm Hg. The patient subsequently has remained stable, with resolution of his chylothorax without the need for further interventions.

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