Pleural Chyle, Pus, or Both?

Abstract

INTRODUCTION: We report a difficult case of bilateral chylothoraces from Kaposi's sarcoma complicated by a left empyema and trapped lung. CASE PRESENTATION: A 25 year old male with AIDS (CD4 count of 314 cells/uL) on antiretroviral therapy presented with two days of fevers, cough, and shortness of breath. Medical history was significant for Kaposi's sarcoma diagnosed one year ago, on monthly doxorubicin infusions. He was febrile to 103°F and tachycardic to 120 beats/minute. Physical exam revealed a small purpuric plaque on his right chest, which was drastically improved from a year ago. He had decreased breath sounds throughout his left hemithorax. Chest radiograph confirmed a large left pleural effusion (Image 1), and a chest tube placement revealed thick milky pleural fluid. Pleural studies showed a triglyceride of 2,283 mg/dL and 26,500 WBC/uL with 90% neutrophils. Culture grew Streptococcus mitis. He was treated with ceftriaxone and defervesced. CT chest showed a trapped left lung and a right pleural effusion. Right chest tube placement also revealed a chylous effusion (Image 2). He underwent left thoracotomy with pleural decortication. A chyle leak was detected with surrounding tissue suspicious for a Kaposi's lesion. The duct was ligated. Postoperatively, high bilateral chylous chest tube output continued. Furthermore, despite dietary modifications, subcutaneous octreotide injections, and a doxorubicin infusion, high output persisted. Lymphangiogram was attempted without success. On hospital day 30, he was started on total parenteral nutrition with a gradual reduction in chylous output. A low fat diet was then reintroduced, and he was finally discharged home. DISCUSSION: This is the fifth case report of bilateral chylothoraces associated with Kaposi's sarcoma. However, this is the first case which was complicated by an empyema and trapped lung. There are two prior case reports of empyema associated with chylothorax, one involving chronic periodontitis and the other involving malignancy. In our case, bilateral chylothoraces likely resulted from obstructive Kaposi's lesions and anatomical variation of the thoracic duct. Microaspiration then led to S. mitis empyema with trapped lung. His immunocompromised status likely contributed to his development of this rare combination of pleural diseases. CONCLUSIONS: Although rare, clinicians should be aware of the possibility of the coexistence of chyle and pus in milky pleural effusions.