Chylothorax in a Patient With ESRD

Abstract

INTRODUCTION: Chylothorax unrelated to trauma may result from lymphatic obstruction from lymphoma or carcinoma. Chylothorax may result from LAM, fungal infections, Tuberculosis, yellow nail syndrome and noonan syndrome. Chylothorax as a complication of endstage renal disease is rare CASE PRESENTATION: 77 year-old African American male with past medical history of hypertension and End-Stage Renal disease on hemodialysis via left subclavian access was admitted to the hospital for Sepsis secondary to UTI. Patient had no prior history of trauma. Physical exam was significant for decreased air entry at the right base without any wheezing or crackles. WBC 13,100 with a left shift, Hb 11.0, BUN 64, creatinine 10.91, BNP 53.78 protein 8.5, albumin 2.5 and LDH 162. Liver function test, coagulation profile, and electrolytes were within normal limits. PPD was negative. Chest x-ray performed in the emergency department showed right pleural effusion. Echocardiogram revealed a normal left ventricular ejection fraction and stage I diastolic dysfunction without significant valvular disease. 1600ml of Pleural fluid obtained from thoracentesis appeared milky white. Fluid analysis: amylase 74, cholesterol fluid <50, total protein 5.8, glucose 160, LDH 94, pH 7.7, and triglyceride 2141. The findings were consistent with chylothorax. Fluid cytology was negative for malignant cells. Serum and urine electrophoresis revealed a polyclonal gammopathy of undertermined significance unchanged over the last 2 years. Cat scan of chest, adomen and pelvis was negative for malignancy, DISCUSSION: There are case reports of HD catheter placement on the left resulting in dissection of the thoracic duct with a left chylothorax but a right chylothorax with a left catheter is unusual.The catheter placement was not related in time to the development of the effusion.There is no evidence of malignancy, liver disease or trauma to the chest. There is no historical data suggesting another etiology. Although the pathogenesis is unknown, rarely chylothorax may complicate nephrotic syndrome. CONCLUSIONS: Renal disease may be considered in the etiology of chylothorax.