Case Presentation: Chylothorax and chylous ascites are lymphatic complications characterized by leakage of triglyceride-rich fluid secondary to damage of the thoracic duct. Few cases in the literature exist regarding chylous complications from chronic lymphocytic leukemia (CLL). We report a rare co-existence of chylothorax and chylous ascites in a patient with CLL.
A 60-year old non-smoker, non-drinker was admitted with dyspnea. Medical history included CLL diagnosed five years prior. He tolerated his first cycle of chemotherapy. On presentation, the patient complained of dyspnea and fatigue. He denied fevers, chest pain, pleurisy, cough, hemoptysis or recent travel. Physical examination revealed diminished breath sounds at the right lung base and a distended, non-tense abdomen. No stigmata of liver disease were present. Admission vitals included hypotension and tachycardia. Laboratory studies were significant for WBC 11.8, creatinine 1.4. ABG: pH 7.38, pCO2 26, pO2 108, O2 99.2%. Chest x-ray showed large right-sided pleural effusion without mediastinal adenopathy. Thoracentesis drained 1600cc of milky fluid from the right lung. Fluid studies revealed: RBCs 10455ug/L, 1256 nucleated cells (39% lymphocytes, 10% monocytes). An exudative effusion was noted based on Light’s criteria. Pleural fluid triglycerides, 233 mg/dl, confirmed suspicion of chylothorax.
A diagnostic paracentesis was performed for new onset ascites. Aspirate yielded 400cc of turbic fluid with triglyceride level of 213 mg/dL, consistent with chyloperitoneum. Ascitic fluid cultures were sterile and cytology demonstrated no malignant cells or neutrophils. A communication between the thorax and the peritoneum was presumed, and later confirmed by the consistent accumulation of chyle into both the left and right pleural space. A decision was made to proceed with VATS and mechanical pleurodesis. The patient improved following conservative dietary management and discharged to a rehabilitation facility.
Discussion: The diagnosis of chylothorax is suggested by triglyceride level greater than 110 mg/dl in pleural fluid. Because chyle is not irritating to the pleura, chest pain is infrequent. Compression of the lung leads to dyspnea. The main complications are malnutrition and depressed immune function due to the loss of nutrients and lymphocytes into the pleural space. Fortunately, chyle is bacteriostatic, and thus rarely complicated by empyema.
Conclusions: Although CLL is often associated with pleural effusion, chylothorax is rare. CLL rarely causes adenopathy significant enough to obstruct the thoracic duct, explaining its infrequent nature. Understanding the causes of chylous ascites and chylothorax in the setting of malignancy can guide future care. As both are extremely rare conditions, there is scant literature on their management.