Respiratory Medicine CME
Volume 2, Issue 1 , Pages 31-32, 2009

Transudative chylous pleural effusion: Case report

  • Mohammad Ali Ghayumi

      Affiliations

    • Department of Pulmonary and Critical Care Medicine, Shiraz University of Medical Sciences, Karimkhan Blvd, Namazi Hospital, Shiraz, Fars 71345/1414, Iran
    • Corresponding Author InformationCorresponding author. Tel./fax: +98 711 6474316.
    • ,
  • Samrad Mehrabi

      Affiliations

    • Department of Pulmonary and Critical Care Medicine, Shiraz University of Medical Sciences, Karimkhan Blvd, Namazi Hospital, Shiraz, Fars 71345/1414, Iran
    • ,
  • Ghanbar Ali Reis Jalali

      Affiliations

    • Department of Nephrology, Shiraz University of Medical Sciences, Shiraz, Iran

Received 2 September 2008; accepted 15 October 2008.

Article Outline

Summary 

Transudative chylous pleural effusion is a very rare entity. Hereby we present a 46 year old man a case of chronic renal failure and nephrotic syndrome with chylous ascites, lower extremity edema and chylous transudative pleural effusion with slight response to ultrafiltration.

Keywords: Chylous effusion, Transudate, Nephrotic syndrome

 

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Introduction 

Chylothorax is an infrequent cause of pleural effusion that is most commonly caused by obstruction or disruption of the thoracic duct. While there are many recognized etiologies of chylothorax, malignancies and trauma related to surgical procedures account for most cases. Chylous effusions are typically exudates rich in triglycerides and chylomicrons. Nevertheless, in a small minority of patients, the chylothorax may be transudative in nature.1 In the sparse available literature regarding transudative chylothorax, the reported etiologies are few and include cirrhosis,2 amyloidosis,1 nephrotic syndrome,3 superior vena caval thrombosis,4 and congestive heart failure.5

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Case report 

A 48yr old man a case of chronic renal failure was referred to department of pulmonology for management of dyspnea. The patient had been diagnosed as a case of nephrotic syndrome with ascites and lower extremity edema from 5 months ago. Patient denied cough, fever, anorexia or weight loss. Labaratory tests showed the following: Hb=9.6g/dL, MCV=82μm3, WBC=5400/mm3, ESR=74mm/h, BUN=18mg/dL, Cr=3.3mg/dL, Na=135meq/L, K=3.7meq/L, P=3.9mg/dL, LDH=186U/L, AST=11U/L, ALT=11U/L, Alk-Pho=204U/L, Lipase=88U/L, Amylase=73U/L, Protein=4.5g/dL, Alb=1.8g/dL, Total Bilirubin=0.3mg/dL, Direct Bilirubin=0.1mg/dL, Chol=238mg/dL, HDL=32, LDL=189, TG=84mg/dL, ANA<0.5, Anti Mitochondrial Antibody(IF)=Negative, Urinalysis=+4 protein, +3Glucose, 24h urine for protein and creatinine was 10gm and 1.2gm respectively. CXR showed moderate right sided pleural effusion (Fig. 1). Echocardiography was normal.

A diagnostic thoracentesis had revealed milky-white fluid and hence chylothorax was suspected6 (Fig. 2). Milky fluid was sterile on culture and negative for malignant cells on two occasions with Protein=1.1g/dL, LDH=99U/L, Sugar=120mg/dL, WBC=75(segment=65, Lymph=10),TG=132mg/dL, Chol=19mg/dL,, ADA=7.5IU/L; the effusion was transudative according to light criteria7 (namely pleural fluid/serum protein ratio, protein fluid/serum LDH ratio, pleural fluid LDH concentration) and chylous by triglyceride greater than 110mG/dL8; hereby establishing transudative chylous effusion. His peritonaeal fluid analysis showed LDH=86U/L, Chol=25mg/dL, protein=0.7g/dL, glucose=121mg/dL, TG=126mg/dL.

The patient was dyspneic and in order to reduce his respiratory embarrassment, hemodialysis with ultrafiltration was recommended with slight beneficiary effect.

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Discussion 

“Chylothorax” is the occurrence of chylous in the pleural space, and is due to damage or blockage of the thoracic duct. The diagnosis is made by analysis of the pleural fluid, which contains high levels of triglycerides, and is confirmed by the finding of chylomicrons.9 Triglyceride levels greater than 110mg/dL are highly suggestive of a chylous effusion. Cholesterol values should be measured simultaneously, since high triglyceride levels can occur in pseudochylothorax,10 but the cholesterol level is always very high (>200mg/dL).

The causes of chylothorax may be divided into four major categories: tumor, trauma, idiopathic, and miscellaneous.11 Although chyle is reported to have protein concentrations in the transudative range, chylous effusions are typically exudative by standard criteria.3

Transudative chylothorax is a very rare entity. Diaz-Guzman et al.1 in a literature review had reported only 13 patients with transudative chylothorax. The etiologies were cirrhosis, heart failure, systemic amyloidosis, superior vena cava obstruction and nephrotic syndrome.

The conventional notion that chylothorax develops when the thoracic duct is obstructed fails to explain events in transudative chylothorax. Translocation of chylous ascitic fluid across the diaphragm is the likely cause of chylothorax in the nephrotic syndrome and in cirrhosis.12, 13, 14 In our case the same laboratory characteristics of ascites and pleural fluid supports the above mentiond hypothesis.

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Conflict of interest statement 

The authors have no conflict of interest to declare.

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References 

  1. Diaz-Guzman E, Culver DA, Stoller JK. Transudative chylothorax: report of two cases and review of the literature. Lung. 2005;183:169–175
  2. Romero S, Martin C, Herná ndez L, et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest. 1998;114:154–159
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  4. Hanna James, Truemper Edward, Burton Edward. Superior vena cava thrombosis and chylothorax: relationship in pediatric nephrotic syndrome. Pediatr Nephrol. 1997;11:20–22
  5. Martín-Escribano P. Chylothorax and chylous ascites due to heart failure. Eur Respir J. 1995;8:1235–1236
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  7. Light RW, MacGregor I, Luchsinger PC, et al. Pleural effusion: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77:507–513
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  10. Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration. 1991;58:294–300
  11. Doerr CH, Miller DL, Ryu JH. Chylothorax. Semin Respir Crit Care Med. 2001;22:617–626
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PII: S1755-0017(08)00085-7

doi:10.1016/j.rmedc.2008.10.003

Respiratory Medicine CME
Volume 2, Issue 1 , Pages 31-32, 2009

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