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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 320-323

Chylothorax in a young child after a palliative cardiac surgery


Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission07-Apr-2020
Date of Acceptance22-Sep-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Amar M Taksande
Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi Meghe, Wardha - 442 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_90_20

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  Abstract 


Chylothorax is an unusual complication in children. It is diagnosed by demonstrating high triglyceride content in the pleural fluid and a low cholesterol concentration in relation to the serum cholesterol. While undergoing cardiothoracic surgery, damage to the thoracic duct may take place which is one of the leading causes of chylothorax. Here, we present a case of chylothorax in a 10-year-old boy who was operated for cyanotic congenital heart disease. He was managed for resolution of chylothorax with various measures such as dietary management, intercostal drainage tube, drugs, and respiratory exercises.
The following core competencies are addressed in this article: Practice-Based Learning and Improvement, Patient care and Procedural skills.

Keywords: Breathlessness, chylothorax, congenital heart disease, thoracic duct


How to cite this article:
Taksande AM, Injeti G, Joshi M, Meshram R. Chylothorax in a young child after a palliative cardiac surgery. Int J Acad Med 2020;6:320-3

How to cite this URL:
Taksande AM, Injeti G, Joshi M, Meshram R. Chylothorax in a young child after a palliative cardiac surgery. Int J Acad Med [serial online] 2020 [cited 2021 Apr 17];6:320-3. Available from: https://www.ijam-web.org/text.asp?2020/6/4/320/304605




  Introduction Top


Chylothorax is formed by the escape of chyle from the thoracic duct or lymphatics into the pleural cavity. The occurrence of chylothorax after congenital heart surgery is a common complication, and morbidity associated with is significant.[1],[2] Chyle accumulates in the pleural cavity following the injury to the thoracic duct, which is a life-threatening situation to the child. Loss of chyle causes respiratory embarrassment, malnutrition, and debility which causes a serious effect on the child.[3],[4] Here, we are discussing a case of chylothorax of traumatic origin which was managed conservatively.


  Case Report Top


A 10-year-old male child, born out of a nonconsanguineous marriage presented with complaints of chest pain and breathlessness for a week. Chest pain radiated to the left shoulder and back, was pricking in character restricted to the left side, and was relieved when he lied on the left lateral position. There was no history of fever, cough, hemoptysis, throat pain, earache, and loss of weight. Palliative surgery Bidirectional Glenn shunt was performed 3 weeks back for an underlying cyanotic congenital heart disease: Dextro-transposition of great arteries with large size ventricular septal defect with large size atrial septal defect with moderate-to-severe valvular pulmonary stenosis. The postoperative period was uneventful. He had suffused conjunctivae, central cyanosis, frontal and parietal bones were prominent, Grade 3 clubbing in all four limbs, and a linear scar mark near the sternal area. On admission, his oxygen saturation was 74%, pulse rate was 92/min and regular, the respiratory rate was 48/min, and blood pressure was normal in all the four limbs. On cardiac examination, a grade 3/6 ejection systolic murmur at the left parasternal area was present. On respiratory examination, decreased chest movements on the left side along with the tracheal shift to the right side. There was no air entry heard on the left side of the chest and a stony dull note was obtained on percussion. His abdomen was soft, non-distended, and non-tender without hepatosplenomegaly.

Laboratory investigations revealed that hemoglobin 17.8 g/dl, white blood cell count 9700 cells/mm3 (pleomorphs - 70%, lymphocytes - 20%), platelets 2.73/mm3, serum sodium 138 mmol/l, serum potassium 3.5 mmol/l, bicarbonate 27 mmol/l, blood urea 14 mg/dL, and serum creatinine 0.7 mg/dL. The eosinophilic count was within the normal limits. Serum albumin was 4.2 g%, serum triglycerides was 104 mg/dl, and total cholesterol was 128 mg/dl %. Chest X-ray suggestive of the left-sided pleural effusion with features of homogenous opacity in the left hemithorax, blunting of the costophrenic angle, mediastinal shift to the right and left half of the diaphragm gets displaced downward [Figure 1]. An ultrasonography of the thorax was also done suggestive of massive pleural effusion of the left lung. About 500 ml of milky white fluid was drained out during diagnostic pleural tapping which was suggestive of chylothorax. This pleural fluid was sent for the following investigations: albumin 2.4 g%, lactate dehydrogenase 164 u/l, glucose 84 mg/dl, pH 7.4, cholesterol 67 mg/dl, and triglycerides 525 mg/dl. Pleural fluid-to-serum triglyceride ratio was >5 and pleural fluid, serum cholesterol ratio was 0.5. Around 2500 cells/mm3 were observed, of which 70% were lymphocytes. The milky fluid was sterile on culture. There was a transient improvement in the symptoms and the child appeared comfortable even in the supine position. After a few days, the patient developed breathlessness again as fluid started to accumulate again. The intercostal drainage tube was secured to alleviate the symptoms. On an average 500–600 ml of fluid continues [Figure 2] to collect in the underwater seal drain for the next 15 days.
Figure 1: Chest X-ray showing left side opacity with a mediastinal shift toward right suggestive of left pleural collection

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Figure 2: Intercostal drainage bag showing chyle drainage

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In view of persistent drainage in the tube in spite of diet, contacting low fat and containing medium-chain triglycerides (MCTs) patient managed with long-acting somatostatin analog (octreotide) in a dose of two microgram/kg/subcutaneously six hourly. He was kept nil by mouth initially and started on parenteral nutrition which consists of lipids, protein, and dextrose. Later, a diet containing high protein, easily digestible MCT fats was allowed. After 15 days, his intercostal drainage tube was removed and he was managed conservatively. Over a period of 45 days, he was monitored for respiratory signs, and a chest X-ray was repeated which shows expanded lung [Figure 3] without any lung opacity on the left side. The child had no sign of respiratory distress and bilateral air entry was equal on respiratory examination.
Figure 3: Chest X-ray after drainage of left chylothorax showing expanded lung

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  Discussion Top


Chylothorax is a form of pleural effusion which could be either a congenital anomaly of the thoracic duct or due to obstruction and trauma to the thoracic duct along its course in the mediastinum leading to drainage of chyle into the pleural spaces. Localized congenital weakness in the duct or abnormal lymphaticopleural connections is the cause for congenital chylothorax. Postoperative chylothorax is seen after BlalockTaussing shunt or surgical management of patent ductus arteriosus.[4],[5] chylothorax after surgical procedures for congenital heart disease poses a challenging clinical situation. Its incidence varies across centers, ranging from 2% to 5%. Sometimes even coughing or weight lifting can lead to ruptures of the duct and chylothorax. Nontraumatic chylothorax causes include acute inflammatory conditions, malignancies, aneurysm, and subclavian vein thrombosis. The collection of the chyle which contains lipid and protein in the pleural space leads to increased risk of infections, prolonged mechanical ventilation, and malnutrition.[5],[6]

Confirmation of chylothorax is by the measurement of pleural fluid and serum levels of cholesterol and triglyceride. A pleural fluid triglyceride exceeding 110 mg/dl in conjunction with a ratio of pleural fluid to serum cholesterol of <1 supports the diagnosis. Since large losses of chyle cause a serious effect in a child, nutritional supplementation either by intravenous hyperalimentation or food-containing medium-chain triglycerides should be added. Diet-containing medium-chain triglycerides preferred over hyperalimentation, as it is cost-effective and decreased the risk of infection. Fats in the diet are absorbed in the form of fatty acids and glycerol through the intestinal mucosa. Long-chain fatty acids are absorbed into lymph as chylomicrons after getting re-esterification, whereas medium-chain fatty acids get transported directly into the portal circulation.[6],[7] Currently, the treatment of chylothorax includes conservative management for 2–4 weeks, during which collected chyle is removed by repeated pleural tapping or intercostal drainage tube. Strategies should be developed to improve the prevention and treatment of chylothorax. Pego-Fernandes et al.[8] found that the outcomes of video-assisted thoracic duct ligation in patients with chylothorax after cardiac surgery are favorable in children. Kumar et al.[9] have reported the diaphragmatic fenestration is an effective and safe strategy for the management of persistent chylous effusions after congenital cardiac surgery. Sirolimus used for the effect on the treatment of lymphangiomyomatosis is also known to decrease the incidence of chylothorax in these sets of patients.[10] Surgical management of the injured duct includes ligation of the duct, obliteration of the pleural space either chemically or surgically to allow healing of the duct.[3],[4] New surgical techniques such as pleurovenous or pleuroperitoneal shunting and thoracic duct embolization have been used with success. In recent times, octreotide which is a somatostatin analog, given either subcutaneously or as an intravenous infusion has showed good outcomes.

As reported, complications of chylothorax are malnutrition, secondary immunodeficiency, fluid and electrolyte disturbances, respiratory distress, increased risk of infections, and thrombosis, none of them occurred in our case. Both lymphangiography and lymphoscintigraphy require the administration of contrast to know the exact location of lymphatic leaks. Our interventional radiologist tried to do it but could not succeed in our case. New imaging techniques such as magnetic resonance lymphangiography are helpful in the understanding of chylothorax, and studies conducted on the embolization of the thoracic duct showed good success rate in whom ligation of the damaged duct was not successful.[7],[8],[9],[10] Conservative, as well as surgical therapeutic interventions, are currently in use, but reports are very less. The traumatic chylothorax is usually a transient condition that resolves by conservative management with the replacement of oral feeding with total parenteral nutrition or avoiding diet containing long-chain fatty acids.


  Conclusion Top


Chylothorax is a complication following cardiac surgery and the conservative treatment remains the first therapeutic option before the surgery is considered.

Declaration of patient consent

We certify that we have obtained all appropriate patient consent forms. In the form, the patient(s)/patient parents have given their consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

This manuscript declares that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. We also attest that this clinical investigation was determined to not require institutional review board/ethics committee review, and the corresponding protocol/approval number is not applicable.



 
  References Top

1.
Macfarlane UR, Holman CW. Chylothorax. Amer Rev Resp Dis 1972;105:287-91.  Back to cited text no. 1
    
2.
Oak SN, Kulkarni BK, Deshmukh H, Kamble M, Borwankar SS. Chylothorax A conservative approach (a case report). J Postgrad Med 1991;37:222B, 223-4.  Back to cited text no. 2
    
3.
Rawat JD, Singh S, Singh G, Chaubey D. Congenital idiopathic chylothorax: A very rare case. J Clin Neonatol 2017;6:205-7.  Back to cited text no. 3
  [Full text]  
4.
Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: An evidence-based management algorithm. J Paediatr Child Health 2008;44:716-21.  Back to cited text no. 4
    
5.
Totadri S, Trehan A, Bhattacharya A, Bansal D, Attri SV, Srinivasan R. Chylothorax in children with cancer: A milky predicament. Indian J Cancer 2017;54:691-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pratap U, Slavik Z, Ofoe VD, Onuzo O, Franklin RC. Octreotide to treat postoperative chylothorax after cardiac operations in children. Ann Thorac Surg 2001;72:1740-2.  Back to cited text no. 6
    
7.
Pego-Fernandes PM, Nascimbem MB, Ranzani OT, Shimoda MS, Monteiro R, Jatene FB. Video-assisted thoracoscopy as an option in the surgical treatment of chylothorax after cardiac surgery in children. J Bras Pneumol 2011;37:28-35.  Back to cited text no. 7
    
8.
Kumar TK, Balduf K, Boston U, Knott-Craig C. Diaphragmatic fenestration for refractory chylothorax after congenital cardiac surgery in infants. J Thorac Cardiovasc Surg 2017;154:2062-8.  Back to cited text no. 8
    
9.
Ohara T, Oto T, Miyoshi K, Tao H, Yamane M, Toyooka S, et al. Sirolimus ameliorated post lung transplant chylothorax in lymphangioleiomyomatosis. Ann Thorac Surg 2008;86:e7-8.  Back to cited text no. 9
    
10.
Zuluaga MT. Chylothorax after surgery for congenital heart disease. Curr Opin Pediatr 2012;24:291-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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