Transcript Chylothorax

Unusual Cause of Pleural Effusion
Dr. Mazen Badawi
Dr. Abdulrahman Al-Demerdash
Prof. Omer Al-Amoudi
Week 1
 63 yrs old Saudi gentleman,
 Presented to ENT clinic with 1 wk
history of:
 Sore
throat, low grade fever, generalized
fatigue
 Diagnosed as URTI, received antibiotics
Week 2
 Partial improvement
 Having heaviness in Rt side of chest
 Received 2nd course of antibiotics for
suspected pneumonia
Week 3
 Patient developed shortness of breath
 Seen in our OPD
 Admitted
Week 3 : History
 Cough, pleuritic chest pain
 Smoker for 35 years, DM and HTN on
oral medications
 Other systemic review was
unremarkable
Week 3 : Examination
 Signs of Rt. Sided moderate pleural
effusion
Week 3 : Examination
 Incidental findings
 Left small breast mass
 Goiter
 Otherwise, normal
Week 3 : Investigations
 CBC, U&E , LFT  normal
 CXR= moderate Rt sided pleural
effusion
Diagnosis so far ?…
Week 3 : Management
 Initial DX Parapneumonic effusion
 Pleural tapping done  light yellowish
fluid  sent for diagnostics
 IV
antibiotics were started
 Chest tube inserted
Analysis
Pleural fluid
Serum
Ratio
Protein
42
70
60%
LDH
121
148
80%
Glucose
8.8
14.8
60%
Cell count
WBC
5333 cells/cc
81% Lymph
3% Mono/Macro
RBC
833
AFB + PCR
-ve
Bacterial stain + cult.
-ve
Cytology
Abundant lymphocytes
Week 3 : Work up
 CT chest =
 LN
• Mediastinal
• Rt hilar
• Para aortic
 Multiloculated,
nodular soft tissue mass at
left breast,
 Goiter
 No parynchymal lung lesion
Week 4
 Chest tube drainage turned to be more
whitish
 Daily drainage = 300cc for more than 2
weeks
?
Analysis
Pleural fluid
Serum
Ratio
Protein
42
70
60%
LDH
121
148
80%
Glucose
8.8
14.8
60%
Cell count
WBC
5333 cells/cc
81% Lymph
3% Mono/Macro
RBC
833
AFB + PCR
-ve
Bacterial stain + cult.
-ve
Cytology
Abundant lymphocytes
Week 4 : The lab story
 pleural TG sample
Surprisingly …
TG =450 mg/dl
Diagnosis :
 TG > 110 mg/dl  chylothorax
 Possibly ruptured thoracic duct, due to :
 Lymphoma : HD, NHL
 Lung CA
 Mets.
Week 5
 Surgeons were hesitant for immediate
mediastinoscopy
 Breast and thyroid lesion were biopsied
Week 6
 Thyroid FNA
 Follicular growth, no malignant cells
 Breast biopsy
 hemangioma
Week 7
 Patient admitted under surgical care,
underwent mediastinoscopy.
 LN histopathology : Invasive keratinizing
squamous carcinoma, well differentiated
 1ry is ? : Lungs, larynx, nasopharynx,
esophagus
Plan
 Localizing primary site, staging
 Treating
 Thank You…