FURTHER HISTORYAs a result of the persistent chylothorax, surgical management of the chylothorax was pursued. One month after admission to the PICU, JB had his right thoracic duct and azygous vein ligated. Despite surgical intervention and TPN with nothing by mouth for one month, our patient continued to have ongoing chylous drainage. As a result, MCT's were restarted.
A repeat chest ultrasound showed persistent bilateral pleural effusions. In comparison to previous chest studies, there was no change in the left side effusion and an increase in right effusion. Concominant with the increasing effusions, our patient developed increasing oxygen needs (1 L/minute via nasal prongs). A lymphoscintigram was done but failed to identify any focal lymphatic drainage sites. No other definite intrathoracic or intraabdominal abnormalities were found. At this point, pleurodesis was considered.
and Chylothorax (3) (7) (8) (9)
Pleurodesis should be considered in symptomatic patients with recurrent pleural effusions. Some of the factors that predict successful drainage include: ability of lung to expand (as confirmed by x-ray), complete drainage of accumulated fluid (<50 - 100 cc in 24 Hours), uniform distribution of the sclerosing agent throughout the pleural membrane, absence of loculations (interferes with distribution of the sclerosing agent), and the nature and dose of the sclerosing agent. For patients with chylothorax, within the literature, very few reports of pleurodesis exist. Pleurodesis has been used successfully in 4 patients who would not tolerate thoracotomy. Some of the potential sclerosing agents include: talc, tetracycline, fibrin glue or OKT3 + doxycycline. The fibrin glue has used in premature infants. However, the local site of chyle leak is preferential as less glue is then used.
FURTHER HISTORYBecause of the persistent high volume chylous effusions of our patient, it was felt that pleurodesis would not be successful.
The lymphatic vascular system develops during the 6th week of gestation as an outgrowth of the venous system or as a "de-novo" differentiation from mesenchymal tissue. The primordial lymphatic tissue join together to form lymphatic channels and 6 lymph sacs. Prior to the 20th week of gestation, the pulmonary lymphatic channels and surrounding mesenchymal tissue are prominent and individual pulmonary lobules can be delineated. After the 20 weeks of gestational age, alveolar tissue grows and lymphatic and connective tissue regress.
WHAT IS THE DIFFERENTIAL DIAGNOSIS FOR CHYLOTHORAX?