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A6665 - Tainted Milk: Dasatinib-Induced Bilateral Chylothorax with Associated Streptococcal Infection
Author Block: W. Brasher1, P. Patel2; 1Internal Medicine, Baylor College of Medicine, Houston, TX, United States, 2Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, United States.
Introduction: Novel chemotherapeutic agents like Dasatinib that inhibit multiple tyrosine kinases have revolutionized management of Chronic Myloid Leukemia(CML), but they have the known side effect of causing symptomatic pleural effusions. There are several reported cases of chylous effusions but none associated with infection . Case Report A 40 year-old male with a past medical history of CML(BCR-ABL positive) in chronic remission on maintenance Dasatinib for three years presented to the emergency room for evaluation of three days of shortness of breath, pleuritic chest pain, and high fevers. He had not had any medication dosage changes, sick contacts, travel, or trauma, and he had been seen one month prior in oncology clinic with stable blood counts. He was hemodynamically stable with a fever of 102 F in the ER. Initial studies revealed normal blood counts besides leukocytosis of 12,000 with 97% neutrophils, and positive blood cultures for streptococcus beta-hemolytic serotype group G. CT chest PE-protocol showed moderate bilateral pleural effusions and associated lower lobe collapse without other abnormalities. He was initially treated with ceftriaxone, and Dasatinib was discontinued. On hospital day two, one liter of pink, milky fluid was obtained via right-sided thoracentesis, and studies were exudative with wbc count of 1750 75% neutrophils, glucose 58 mg/dl, and triglycerides 348 mg/dl with chylomicrons detected. Cytology showed diffuse inflammatory cells; culture and gram stain were negative. The following day left sided thoracentesis revealed a more clear pink exudative fluid exudate a wbc count of 1250 75% neutrophils and triglycerides 82 mg/dl. Due to concern for complicated bilateral parapneumonic effusions given continued fever, complicated ultrasound appearance and fluid studies, chest tubes were sequentially placed with intra-pleural TPA/Dornase alpha treatment. The patient’s fevers and symptoms improved, and both tubes were removed prior to discharge with minimal residual effusion. On follow-up with pulmonary and hematology/oncology 1-2 weeks after discharge, the patient was doing well with only trace effusions present.Discussion To our knowledge, no Dasatinib-associated effusions have been reported to be associated with infection or bacteremia. Several have been reported to be consistent with atraumatic chylous effusions, and almost all are lymphocyte predominant. He likely developed chylous effusions due to Dasatinib before acquiring streptococcal infection from possible oral inoculation. This case highlights both the need for timely recognition of side effects of new chemotherapeutic agents and the need for prompt thoracentesis in all new effusions to exclude infection.