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A3144 - Recurrent Bilateral Chylothorax in a Patient with Malignant Mesothelioma
Author Block: S. Brahmandam, G. Hays; Wright State University Boonshoft School of Medicine, Dayton, OH, United States.
Introduction: Chylothorax is the presence of lymphatic fluid in the pleural space, typically right sided due to alteration of the thoracic duct. Confirming the diagnosis requires the presence of milky fluid with high level of triglycerides. We describe a case of bilateral chylothorax non-traumatic etiology secondary to malignant mesothelioma.
Case: 63 year-old-male with a past medical history significant for alcohol induced cirrhosis, sarcoidosis, positive quantiferon, and unintentional weight loss presented for outpatient left-sided thoracentesis due to bilateral pleural effusions seen on CT abdomen pelvis. Initial biochemical analysis of pleural effusion showed 1825/mm3 white blood cells, glucose 95mg/dl, LDH 109 U/L protein 5.4 gm/dl, pH 7.426. Patient was admitted and ID was consulted due to concern of potential TB. A right-sided thoracentesis performed on day two of hospitalization appeared milky in color. Left and right thoracentesis revealed a triglyceride level of 349 and 302 mg/dL and a cholesterol level of 90 and 91 mg/dL respectively. With pleural fluid analysis inconsistent with TB, patient was discharged with follow up. Patient was readmitted with worsening dyspnea and abdominal discomfort. After an unimpressive abdominal MRI, low AFP, and negative HIV screen, a PET scan demonstrated uptake with SUV of 4 to 7 suggestive of carcinomatosis. Subsequent omentum biopsy was consistent with metastatic mesothelioma. Additional thoracentesis resulted in removal of 1400 cc of milky effusion where flow cytometry revealed atypical mesothelial cells. Oncology initiated cisplatin/alimta at discharge. Patient continued to develop refractory symptomatic pleural effusions requiring frequent thoracentesis. As his clinical status deteriorated, he was evaluated and offered PleurX catheter placement after risk discussion. Patient was agreeable; after placement patient continued to have improvement in dyspnea while continuing cisplatin/alimta therapy. Patient's effusions eventually decreased to where the PleurX catheter was removed. Patient currently remains without return of effusions.
Discussion: While lymphoma is the most common cause of non-traumatic chylothorax, fewer than five cases of chylothorax secondary to malignant mesothelioma have been reported. Bilateral chylothorax are rare and even rarer in mesotheliomas where pleural effusions are typically unilateral. Current literature recommends surgical intervention for recurrent chylothorax among other measures, but there has been no report of the use of PleurX catheter for improvement of respiratory symptoms. Malignant mesothelioma rarely manifests with bilateral chylothorax. Literature review shows very few cases of bilateral chylothorax associated with mesothelioma. This demonstrates the use of PleurX catheter in treating recurrent symptomatic bilateral chylothorax secondary to mesothelioma with improvement of respiratory symptoms.