Chylothorax is the occurrence of chyle (lymph) in the pleural cavity secondary to damage of the thoracic duct. It is a rare form of pleural effusion which appears as a milky white turbid fluid. Malignancy is the leading cause of nontraumatic chylothorax while inadvertent surgical injury to the thoracic duct is the major cause of traumatic chylothorax. We report a case of spontaneous left-side chylothorax following septic pulmonary embolization (SPE) with Methicillin-Resistant Staphylococcus aureus (MRSA). This is a rare case of a nonmalignant, nontraumatic, and nontuberculous spontaneous chylothorax which was conservatively treated with fibrinolysis and diet modification.
The accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct results in chylothorax. It is an uncommon cause of pleural effusion with high content of triglycerides. The presence of chylomicrons in the pleural fluid is the definitive diagnostic criterion of chylothorax [
An eighteen-year-old previous healthy male was admitted for worsening chest pain, cough, and dyspnea. Chest computed tomography (CT) (Figure
Chest computed tomography (CT) on admission showing bilateral pulmonary nodules consistent with septic pulmonary embolization (SPE) in the setting of Methicillin-Resistant Staphylococcus aureus (MRSA) bacteremia.
Repeat chest computed tomography (CT) on hospital day twelve (12) showing more pronounced cavitary lesions and moderate loculated left lower lobe pleural effusion.
Pleural fluid from left chest drainage with milky appearance consistent with chylothorax.
Chest X-ray showing interval improvement of left chylothorax 10 days after intrapleural fibrinolytics and diet modification.
The accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct results in chylothorax. It is an uncommon cause of pleural effusion with high content of triglycerides, and the presence of chylomicrons is the definitive diagnostic criterion of chylothorax [
Chylothorax resulting from septic pulmonary embolism has not been reported in the literature. In our case, MRSA bacteremia led to septic pulmonary embolism. Pulmonary effusion and pulmonary abscess may be seen in cases of septic pulmonary embolization (SPE). In a systematic review of patients with SPE, pleural effusion is seen on 32% by X-ray and 29% by chest computed tomography (CT) imaging [
Chylous pleural effusions are typically described exudative lymphocytic pleural effusions with milky appearance. In a retrospective study, chylothoraces may present with variable pleural fluid appearance and biochemical characteristics [
Empyema was considered a differential diagnosis in our case given the loculated appearance of fluid on chest imaging. The pleural fluid’s milky appearance, elevated fluid triglyceride, unremarkable pleural fluid pH, and WBC made us consider chylothorax the predominant pathology. The rare coexistence of empyema and chylothorax, known as empyematous chylothorax, is possible in this case given the overlapping biochemistry of the pleural fluid. In small case series, pleural fluid triglycerides in the chyliform range in the setting of acute bacterial parapneumonic effusion and empyema may indicate severity of the disease [
The treatment approach to chylothorax varies in that some clinicians adopt early surgical intervention while others adopt a conservative approach. Though the conservative approach may have a role to play in small chylothoraces, therapeutic thoracentesis or chest tube drainage is the initial step in large symptomatic chylothoraces. The initial output for this case was about 300 mL only; thus, our team has elected to drain the tube and modify the diet. Conservative treatment includes the use of a low-fat diet supplemented with medium-chain triglycerides (MCT) and/or total parenteral nutrition (TPN) [
Since our repeat CT of the chest showed evidence of loculated pleural fluid, two (2) doses of Alteplase were instilled intrapleurally. The role of fibrinolytics is not established but has been proposed for patients with idiopathic chylothorax who failed conservative therapy but refused surgery in one case report [
The authors declare that there is no conflict of interest regarding the publication of this paper.