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A3150 - A Novel Use of Intrapleural t-PA/DNase Therapy for Loculated Chylothorax
Author Block: B. McKinney1, M. Pate2, N. W. Todd3, A. Papali3; 1University of Maryland Midtown Campus, Baltimore, MD, United States, 2University of Maryland Medical Center, Baltimore, MD, United States, 3Pulmonary/Critical Care, University of Maryland School of Medicine, Baltimore, MD, United States.
Introduction: Chylothorax is frequently encountered in clinical practice, but loculated chylothorax is rare and optimal management remains unclear. We describe the first known case of loculated chylothorax successfully treated with intrapleural tissue plasminogen activator (t-PA) and deoxyribonuclease (DNAse). Case Report: A 37-year old African-American man with history of well-controlled HIV (CD4 603, VL undetectable at admission), recurrent tricuspid valve endocarditis with bio-prosthetic valve replacement 3 years prior to admission, and gunshot wound 17 years prior presented with shortness of breath. On ICU admission, he was normotensive and afebrile with oxygen saturations of 88% on non-rebreather mask. Lung sounds were diminished at the bases bilaterally without wheezing. Initial laboratory findings showed a normal white blood cell count. CT scan of the chest demonstrated large, loculated pleural collections bilaterally, while bedside thoracic ultrasound revealed septations and fibrin stranding within the fluid collections. Broad-spectrum antibiotics were started empirically for presumed empyema thoracis and a 14-French pigtail catheter was placed on the left side with subsequent drainage of yellow, cloudy fluid. Pleural fluid analysis revealed an exudate with no organisms seen on gram stain, WBC count of 944 per mcL (94% lymphocytes) and a triglyceride count of 310 mg/dL. Fluid culture was negative. By ICU day 2, pleural fluid drainage was minimal, but repeat bedside ultrasound showed persistent septated fluid pockets. DNase (5 mg) and t-PA (10 mg) were instilled into the pleural space twice daily for four days with marked increase in fluid drainage. The patient’s dyspnea dramatically reduced, allowing for transfer out of the ICU. Prior to discharge, a surgical pleural biopsy was considered for definitive diagnosis. Due to concern about his comorbidities, however, outpatient thoracic imaging and pulmonary follow-up was favored. Discussion: While intrapleural fibrinolytic therapy is well-described for empyema, its use in chylothorax has been reported only once previously (streptokinase). To our knowledge, this is the first description of t-PA and DNase for treatment of non-draining loculated chylothorax. Intrapleural fibrinolytic therapy should be considered as a therapeutic option in this clinical scenario, although further study is required to determine safety and effectiveness.