Concurrent Occurrence of Chylothorax and Chyloperitoneum in Non-Hodgkin’s Lymphoma

Tariq Sharman^1, and Jeffrey Song¹

¹Department of Internal Medicine, Southern Ohio Medical Center, Portsmouth, U.S.A.

Cite this paper

Tariq Sharman and Jeffrey Song. Concurrent Occurrence of Chylothorax and Chyloperitoneum in Non-Hodgkin’s Lymphoma. American Journal of Medical Case Reports. 2019; 7(10):223-227. doi: 10.12691/AJMCR-7-10-1

Abstract

Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. Chylothorax is classified as non-traumatic or traumatic. Non-traumatic chylothorax is mainly caused by malignant etiologies accounting for more than 50% of chylothorax diagnoses. Lymphoma is the most common etiology. Chyloperitoneum is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity, which can occur as a result of trauma or obstruction of the lymphatic system. Chylous ascites is an uncommon finding that can be caused by malignancy, cirrhosis and lymphatic disruption after abdominal surgery. The combination of chyloperitoneum and chylothorax is rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. The Patient is an 82 year old Caucasian male who presented with worsening shortness of breath and abdominal distension. Chest X-ray showed moderate left sided pleural effusion. Bedside ultrasound-guided paracentesis and thoracentesis revealed milky ascetic and pleural fluid respectively. Triglyceride level was 271 mg/dl in the ascetic fluid, and 221 mg/dl in the pleural fluid. Pleural fluid was exudative with lymphocytic predominant cell count and negative cytology. Lymph node biopsy confirmed Non-Hodgkin’s Lymphoma causing the concurrent chylothorax and chyloperitoneum.

Keywords

chyloperitoneum, chylothorax, chyle, pseudochylothorax, chylous ascites, lymphoma, thoracentesis, pleural effusion, triglycerides, lymphoperitoneal fistula, giant lymph node hyperplasia, sarcoidosis, tuberculosis, histoplasmosis, yellow nail syndrome, systemic lupus erythematosus, noonan syndrome, nephrotic syndrome

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010; 104: 1-8.
[2]	Doerr CH, Allen MS, Nichols FC, Ryu JH. Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005; 80: 867-70.
[3]	Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg. 2007; 32: 362-9.
[4]	Smati B, Sadok Boudaya M, Marghli A, et al. Management of postoperative chylothorax. Rev Mal Respir. 2006; 23: 152-6.
[5]	Maldonado F, Hawkins FJ, Daniels CE, et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009; 84: 129-33.
[6]	Das DK. Serous effusions in malignant lymphomas: a review. Diagn Cytopathol. 2006 May; 34(5): 335-47.
[7]	Berkman N, Breuer R, Kramer MR, Polliack A. Pulmonary involvement in lymphoma. Leuk Lymphoma. 1996; 20: 229-37.
[8]	Xu K, Hu X, Tian X, et al. Clinical analysis of 123 cases of chylous effusion. Zhonghua Yi Xue Za Zhi. 2011; 91: 464.
[9]	Shah RD, Luketich JD, Schuchert MJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg. 2012; 93: 897-904.
[10]	Hillerdal, G. Chylothorax and pseudochylothorax. Eur Respir J. 1997; 10: 1157-1162.
[11]	Nair, S.K., Petko, M., and Hayward, M.P. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg. 2007; 32: 362-369.
[12]	Riquet, M. et al. Chylomediastinum after mediastinoscopy. Apropos of a case. Rev Mal Respir. 1993; 10: 473-476.
[13]	McWilliams, A. and Gabbay, E. Chylothorax occurring 23 years post-irradiation: literature review and management strategies. Respirology. 2000; 5: 301-303.
[14]	Bolger, C. et al. Chylothorax after oesophagectomy. Br J Surg. 1991; 78: 587-588.
[15]	Kurekci, E., Kaye, R., and Koehler, M. Chylothorax and chylopericardium: a complication of a central venous catheter. J Pediatr. 1998; 132: 1064-1066.
[16]	Van Renterghem, D.M. and Pauwels, R.A. Chylothorax and pleural effusion as late complications of thoracic irradiation. Chest. 1995; 108: 886-887.
[17]	Rahman, N.M., Chapman, S.J., and Davies, R.J. Pleural effusion: a structured approach to care. Br Med Bull. 2004; 72: 31-47.
[18]	Maldonado, F. et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009; 84: 129-133.
[19]	Merrigan, B.A., Winter, D.C., and O'Sullivan, G.C. Chylothorax. Br J Surg. 1997; 84: 15-20.
[20]	Diaz-Guzman, E., Culver, D.A., and Stoller, J.K. Transudative chylothorax: report of two cases and review of the literature. Lung. 2005; 183: 169-175.
[21]	Tie, M.L., Poland, G.A., and Rosenow, E.C. 3rd. Chylothorax in Gorham's syndrome. A common complication of a rare disease. Chest. 1994; 105: 208-213.
[22]	Worthington, M.G. et al. Isolated thoracic duct injury after penetrating chest trauma. Ann Thorac Surg. 1995; 60: 272.
[23]	Macfarlane JR, Holman CW. Chylothorax. Am Rev Respir Dis 1972; 105: 287.
[24]	Fernandez FG, Denlinger CE, Patterson GA, et al. Massive bilateral chylothoraces complicating mediastinal granulomatous disease. Ann Thorac Surg 2009; 88: 1012.
[25]	Tutor JD, Schoumacher RA, Chesney PJ. Chylothorax associated with histoplasmosis in a child. Pediatr Infect Dis J 2000; 19: 262.
[26]	Nadolski G. Nontraumatic Chylothorax: Diagnostic Algorithm and Treatment Options. Tech Vasc Interv Radiol 2016; 19: 286.
[27]	Blankenship ME, Rowlett J, Timby JW, et al. Giant lymph node hyperplasia (Castleman's disease) presenting with chylous pleural effusion. Chest 1997; 112: 1132.
[28]	Ryu JH, Doerr CH, Fisher SD, et al. Chylothorax in lymphangioleiomyomatosis. Chest 2003; 123: 623.
[29]	Terzi A, Furlan G, Magnanelli G, et al. Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication. Thorac Cardiovasc Surg 1994; 42: 81.
[30]	Prakash, UBS. Chylothorax and pseudochylothorax. Eur Respir Mon 2002; 7: 249.
[31]	Maldonado F, Hawkins FJ, Daniels CE, et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009; 84: 129.
[32]	Sarsam MA, Rahman AN, Deiraniya AK. Postpneumonectomy chylothorax. Ann Thorac Surg 1994; 57: 689.
[33]	Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31: 743.
[34]	Thaler MA, Bietenbeck A, Schulz C, Luppa PB. Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions. Clin Biochem 2017; 50: 13.
[35]	Acta Clin Belg. Chylothorax and chylous ascites due to malignant lymphoma. 1995; 50(1): 20-4.