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A3237 - Chylous Pleural Effusion: A Rare Complication of Chronic Lymphocytic Leukemia
Author Block: E. R. Rashed, P. Rattner, S. Kothadia, J. Kim; Pulmonary and Critical Care, VA New Jersey Healthcare system, East Orange, NJ, United States.
IntroductionThoracic involvement can be a source of significant morbidity and mortality of patients with Chronic lymphocytic leukemia (CLL). Chylothorax, specifically is a rare manifestation of CLL. It usually occurs secondary to trauma or surgery of thoracic duct. We present a case of a 68-year old male with a history of CLL with a complaint of dyspnea, found to have chylous pleural effusions. Clinical Case A 68-year-old male, with PMH of CLL, systolic heart failure, coronary artery disease with bypass 3 months prior, presented with progressive dyspnea over 1 month. Vital signs were significant for oxygen saturation of 96% on 3L NC. Exam revealed diminished breath sounds, fremitus, and abdominal distention. Lab work was significant for leukocytosis, mild hypercalcemia, and mild renal insufficiency. Chest radiograph showed bilateral pleural effusions, greater on the left. The patient was initially treated for a heart failure exacerbation, however, there was no improvement in respiratory status or repeat radiograph. Thoracentesis was performed and 1400 mL of milky fluid was removed from the left side. Fluid analysis revealed 3.12 g/dl of protein, 115 unit/L of LDH, and 104 mg/dl of glucose, and a triglyceride level of 504 mg/dl consistent with an exudative chylous pleural effusion. Fluid WBC count was 4207 with 59% monocytes and 40% lymphocytes. Fluid culture and stain were negative. Flow cytometry showed monotypic B-cells consistent with CLL. Due to re-accumulation, the decision was made to place bilateral thoracostomy tubes and perform pleurodesis. The patient eventually went on to receive chemotherapy for his CLL. Discussion Non-traumatic chylothorax most commonly results from malignant obstruction of the thoracic duct, usually by lymphoma, with CLL infrequently identified as a cause. However, a recent review by Khanijo et al, found that pleural involvement was the 2nd most common thoracic complication seen in CLL. The mechanism in development of chylothorax in CLL is not clear but may result from direct obstruction from mediastinal lymphadenopathy, reduced flow within the thoracic duct from abnormal lymphocytes, or traumatic disruption. Treatment of chylothorax is determined by etiology and conservative management may be an acceptable approach in the absence of malignancy. Our patient’s recent history of thoracic surgery and CHF may have caused a delay in diagnosis, fortunately, for our patient, the delay did not affect his overall outcome. Conclusion Chylothorax secondary to CLL is uncommon but should be considered in the appropriate clinical setting as to avoid costly delays in treatment.