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|Year : 2011 | Volume
| Issue : 3 | Page : 259-261
A curious case of chylothorax
AA Karnik1, NP Patel2
1 Department of Medicine, Division of Cardiology, Boston Medical Center, Boston, MA, USA
2 Division of Pulmonary Medicine, Reading Hospital and Medical Center, Reading, PA, USA
|Date of Web Publication||22-Sep-2011|
A A Karnik
Department of Medicine, Division of Cardiology, Boston Medical Center, Boston, MA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Karnik A A, Patel N P. A curious case of chylothorax. J Postgrad Med 2011;57:259-61
We report a unique case of recurrent spontaneous bilateral chylothoraces with supraclavicular chyle collection due to push-ups and propose a mechanism of injury for these findings. A 47-year-old woman presented with 2 days of dyspnea, left shoulder pain and a fullness in the left supraclavicular region that began following a prolonged session of push-ups the day prior. She had no prior cardiac history or lymphatic problems and denied recent trauma. Physical examination was remarkable for fullness of the left supraclavicular region and dullness to percussion and diminished breath sounds from mid-chest to the lung bases bilaterally. Chest film showed bilateral pleural effusions. Computed tomography (CT) of the chest showed large bilateral pleural effusions [Figure 1] as well as left shoulder soft tissue edema with a 2.2Χ1.3-cm soft tissue axillary lesion.
|Figure 1: CT of the chest demonstrating large bilateral pleural effusions|
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Thoracentesis was performed on the right pleural effusion with removal of 800 ml of exudative milky fluid. Pleural fluid triglyceride level was 3935 mg/dl. Pleural fluid to serum cholesterol ratio was less than one. Cytology showed no malignant cells. Ultrasound of the left upper extremity was normal. To clarify the lesion seen on CT, a mammogram was performed which showed a complex cyst. PPD was negative. The patient was conservatively managed on a long-chain fat acid restricted and medium-chain triglyceride supplemented diet and told to continue this as an outpatient. These are absorbed directly into the portal system rather than gastrointestinal lymphatics, thus reducing lymphatic flow and accelerating healing of the thoracic duct.  Serial chest films showed resolving effusion over the course of 4 days. One month later, the patient developed recurrent pleural effusions after resuming push-ups and a regular diet. An evaluation for malignancy was initiated: Bone marrow aspirate was unremarkable. Core biopsy of the axillary cyst showed benign fibrocystic changes. Magnetic resonance imaging of the upper body did not show lymphatic obstruction or other abnormalities. She was again medically managed and the effusions had not recurred at 1 year follow-up.
A chylothorax is an accumulation of chyle in the pleural space and occurs when flow through the thoracic duct is disrupted anywhere along its course from the cisterna chyli to where it terminates at the left jugular and subclavian veins [Figure 2].  Most 'spontaneous' cases in adults are probably from minor non-penetrating trauma. Injury to the thoracic duct can occur as a result of hyperextension of the spine or fractured vertebra.  Weight lifting, straining, coughing, vomiting, childbirth and stretching while yawning are known to cause 'spontaneous' chylothorax.  Malignancy should be considered as a cause of unexplained chylothorax as it can precede a diagnosis of malignancy, especially lymphoma, by several months.  Apart from diet, other means of treating chylothorax include octreotide, pleuroperitoneal shunt and pleurodesis. 
|Figure 2: Anatomy of the thoracic lymphatic system. Open arrow indicates level of thoracic duct injury which would result in bilateral chylothorax. Closed arrow indicates location of injury which would cause supraclavicular lymph accumulation|
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Our patient did 25 push-ups daily for several years with an extended session 1 day prior to development of chylothorax. Chylothorax is usually right sided since most of the thoracic duct traverses the right hemithorax. Exercise-induced chylothorax is rare;  to our knowledge this is the first report of bilateral chylothorax resulting from push-ups. Bilateral chylothorax suggests disruption of the thoracic duct around the third or fourth vertebra where it crosses the midline [Figure 2].  In our patient, spine hyperextension and flexion/extension of the scapulothoracic joint and elevated intrathoracic pressures generated by repetitive Valsalva maneuver during push-ups put stress on the thoracic duct in that region.
The origin of the supraclavicular chyle collection is more obscure. Injury to the thoracic duct as it empties into the left jugulo-subclavian junction would allow chyle to spill into the supraclavicular fossa [Figure 2].  Increased intrathoracic pressure from push-ups may be transmitted up the thoracic duct, provoking injury where the duct turns sharply and empties into the great vessels.
| :: References|| |
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[Figure 1], [Figure 2]