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A3225 - Fungus Among Us: A Rare Case of Infected Chylothorax
Author Block: N. Fitzpatrick; Pulmonary and Critical Care, Hershey Medical Center, Hershey, PA, United States.
Introduction: Chylothorax is defined as the presence of chyle in the pleural space and is usually caused by traumatic or malignant involvement of the thoracic duct. Chylothoraces are thought to have sterile pleural fluid, and reports of concomitant infection are extremely rare.
Case Presentation: A 30 year-old male was referred for evaluation of a right-sided pleural effusion. His case began two months prior, when he underwent heart transplantation for a non-ischemic cardiomyopathy with refractory congestive heart failure. Intra-operatively, three chest tubes were left in place which were discontinued on post-operative day eight, after minimal serosanguinous output. He received meropenem, daptomycin and caspofungin for one week post-transplant for prophylaxis and was started on immunosuppressive therapy (tacrolimus, anti-TG, methylprednisolone and mycophenolate). Two weeks after transplant, his course was complicated by Candida parapsilosis fungemia, which cleared with resumption of caspofungin. Serial chest x-rays were negative for pleural effusions until post-operative day 27, when small bilateral effusions were observed. He was discharged on post-operative day 38. On post-operative day 50, the patient returned with a complaint of chest pain and was found to have a moderate right pleural effusion. Thoracentesis yielded 1.5 liters of milky-appearing exudate with mixed cellularity (48% neutrophils), triglycerides of 89 mg/dL, pleural NT brain natriuretic peptide of 7750 pg/ml, and cultures positive for Candida parapsilosis. Lipid electrophoresis revealed chylomicrons and confirmed chylothorax. Per patient preference, a chest tube was not pursued and the patient received oral fluconazole for three months with resolution of the effusion in outpatient follow-up.
Discussion: Chylothorax is the most common form of lipid effusion, and is typically induced by disruption of the thoracic duct. The effusions are typically lymphocytic exudates with a triglyceride count >110 mg/dL. The diagnosis can be confirmed with lipid electrophoresis demonstrating the presence of chylomicrons. Infection of a chylothorax is rare due to the high T-cell lymphocyte and immunoglobulin content of chyle with very few case reports of bacterial infection and two of fungal empyema.
This pleural effusion was thought to be multifactorial: chylothorax secondary to thoracic duct disruption during heart transplant and fluid overload. This case is the second report of fungal infected chylothorax in a patient with candidemia, suggesting the need for pleural fluid culture and thorough work-up when clinically indicated, as the high immunoglobulin and T-cell count of lymphatic fluid might not prohibit all forms of infection.