Case Presentation: A 69-year-old female with no prior past medical history who presented to the ED with complaints of shortness of breath. Chest-x-ray was found to be positive for right sided pleural effusion. A thoracentesis was performed and pleural fluid found to be exudative per Light’s criteria. Fluid cytology and cell count were within normal limits. Echocardiogram was negative for heart failure. Fluid triglyceride levels were noted to be significantly elevated. Patient was diagnosed with chylothorax. Initially 1.5L of pleural fluid was drawn but pleural effusion quickly returned. After consultation with cardiothoracic surgery a chest tube was placed. Greater than 1L of chyle continued to drain in 24 hours. Lymphangioscintigraphy was negative for any thoracic duct abnormality. The patient eventually responded well to dietary modifications, octreotide, and midodrine. Patient received a full work up for possible causes of her chylothorax. Extensive imaging ruled out malignant or infiltrative processes at the thoracic duct. No prior trauma or surgery was performed in the region. A right upper quadrant ultrasound however was found to be positive for cirrhosis. The patient on the other hand had no stigmata of liver disease.
Discussion: Cirrhosis of the liver is known to cause a stigmata of presentations. These patients often have esophageal varices, ascites, hepatorenal-pulmonary syndromes, hydrothorax, etc. Many patients present with multiple different manifestations of liver disease with jaundice, icterus, spider nevi, encephalopathy, and many more. Very rarely the presenting complaint of cirrhosis is pleural effusions found to be chylothorax. This patient was initially thought to have idiopathic cause to her high output chylothorax. Patient had no recent trauma or surgery. Evaluations were negative for heart failure, enteropathy, malignancies, etc. Instead the patient was found to have cirrhosis on imaging without other significant manifestation of liver disease. This rare presentation of cirrhosis reminds us to always keep our differential broad. It also reminds us that chylothorax is a rare complication of cirrhosis.
Conclusions: Chylothorax develops after chyle exudes into the pleural space causing noticeable pleural effusions on chest radiographs. This is often caused by any form of dysfunction through the thoracic duct. Often times the cause of chylothorax is linked with surgery or trauma to the region. Other potential causes include malignancies including lymphomas, leukemias. Some patients have infiltrative disease like sarcoidosis or amyloidosis. Other patients develop chylothorax from enteropathy, cirrhosis, etc. Some patients also have lymphangiectasia or lymphatic conduction disorders. Nonetheless these patients require extensive workup for their chylothorax. Treatment is often limited medically including fluid & diet optimization. Patients who fail medical management often require surgical or radiological intervention to prevent long term malnourishment.