Idiopathic Massive Bilateral Chylothorax : A Case Report

Introduction : Chylothorax is an uncommon medical condition caused by the accumulation of chylous fluid in the pleural space. Chylothorax has no predilection for sex or age. The prevalence after various cardiothoracic surgeries is 0.2% to 1%. Mortality and morbidity rates are around 10%. Respiratory distress may occur due to compression of the lung by the accumulated fluid. Management and approaches to treating the condition require multidisciplinary therapy, starting from non-pharmacological, pharmacological, to interventional management. Case Report : A 57-year-old Man patient was referred to the emergency room with chief complaint of shortness of breath. Reduced breathing sound on both lung fields. No previous history of cancer or thoracic surgery were found. X-ray examination had found bilateral pleural effusion. Thoracocentesis and pleural fluid analysis was performed with total of 6800 cc serosanguinous, whitish fluid was extracted from both of the lung. The patient was diagnosed with chylothorax. Lymphangiography and embolization was performed on the leak on left thoracic duct (T10) from right lymph node. Antibiotic was also given to treat the community acquired pneumonia that could be one of the possible etiology on this patient. Dietary modification with low fat diet and Ocreotide was also given to this patient as one of the treatment modalities. Discussion : The diagnosis of Chylothorax on this patient was established based on pleural fluid analysis and evidenced by lymphangiography examination by the presence of a leak in the thoracic lymphatic duct. Various modalities to diagnose this condition have been carried out with inconclusive results. Non-pharmacological, pharmacological and radiological interventions with embolization through lymphangiography are proven to be able to stop leaks and reduce symptoms in this patient. Conclusion : Chyle leak to the pleural space may compress the lung and cause respiratory distress. Combinaton of thoracocentesis, embolization of the leakage, dietary intake modification and administration of ocreotide may help prevent further chylous fluid accumulation.


Introduction
Chylothorax is an uncommon medical condition characterized by accumulation of chyle in the pleural space.
Numerous etiologies for the case had been suggested, with the most common being previous history of thoracic surgery.

Case Report
Mr. R, a 57-year-old patient presenting to the emergency room with chief complaint of shortness of breath.The patient had felt shortness of breath approximately 3 months ago.The shortness of breath had worsened about a week ago.
The patient had also complained chest pain during breathing in.Previously, the patient had also reported occasional, shortness of breath for about 30 years ago.During the time period, the patient had never sought medical care.The patient had reported that his shortness of breath worsened during physical exertion.The patient denied any history of swelling extremities or shortness of breath when lying down on his back.Total 6800 cc of pleural fluid were extracted from both of the lung (Figure 2).

Discussion
Chylothorax is defined as a collection of chyle on thoracic cavity.
Etiology of the chyle leak from thoracic duct were broadly classified into traumatic and non-traumatic (Figure 5). (2)The   glucose and fat-soluble vitamins. (4)oracocentesis in this case is only a temporary intervention in order to improve the pulmonary function of the patient.Due to the massive amount of chyle leakage (more than 5,000 mL in total in less than a week), the patient was opted to receive lymphangiography to detect the location of the leak and perform embolization afterwards to reduce the amount of leakage (5) .
Somatostatin and its analogue exert a broad spectrum of inhibitory actions in many organs, including the central nervous system, the pituitary gland, the liver and the pancreas, as well as the gastrointestinal tract. (6)The inhibition of serotonin and ligation was advised. (7)The possible etiologies of chylothorax are on Figure 5.

Conclusion
with glue : lipiodol (1 : 6) 1.75 cc from right inguinal lymph node and flushed afterwards with D5% 6 cc.The leakage had been reduced (confirmed with fluoroscopy and DSA examination).Additional CT scan had found pneumonia with inferior lobe bronchiectasis with bilateral fluid accumulation (Figure 4).Based on the patient factors, the Pneumonia Severity Score (PSI) was 67 (risk class II).The sputum culture results were negative.The patient was diagnosed with bilateral chylothorax and communityacquired pneumonia.Empirical antimicrobials were given to the patient to treat the community acquired pneumonia that possibly could be one of the etiology of his condition.Low fat diet and Octreotide (3 x 100 mcg) were prescribed to prevent further chyle buildup on pleural space.We still follow the patient up until now and he is remain stable with no history of worsening symptomps.

Figure 1 .Figure 2 .
Figure 1.Bilateral pleural effusion found on thorax X-ray during admission of chyle may result in differing clinical signs.A chylothorax has been defined as fluid with either or both triglycerides >110mg/dL and the presence of chylomicrons, which are considered the gold standard for diagnosis. (2)Rapid loss of chyle may cause symptoms such as hypovolemia and respiratory issues due to the pleural space being filled with fluid.In sufficiently severe cases, some patient may present with signs of malnutrition due to the loss of proteins, fats, and vitamins.Electrolyte loss and the resulting electrolyte abnormalities detected during the examination may be found.Chylothorax may occur due congenital, traumatic, neoplastic, or other causes; the bulk of the cases occur as a complication from previous thoracic surgery.In this case, it is assumed that the patient had no known cause of chylothorax.No previous reports of malignancy or thoracic surgery prior to the admission.The idiopathic chyle leak of the patient was masked due to the frequently prescribed Symbicort nebulization during the shortness of breath.Hence, the patient's presentation with noticeable respiratory distress that remained unresolved after nebulization.Notably, the patient had no previous history of asthma, chronic obstructive pulmonary disease (COPD), or other medical conditions that require the use of inhaled corticosteroids during shortness of breath.No previous studies were found in regards to the effects of prior inhaled corticosteroid use with the risk of chylothorax.

Figure 3 .
Figure 3. Lymphangiography found a leakage to the horizontal direction on left thoracic duct (T10)

Figure 4 .
Figure 4. Thorax CT scan found pneumonia with inferior lobe bronchiectasis with bilateral fluid accumulation after Thoracocentesis was performed.
other intestinal peptides produces an increase in water absorption and intestinal transit and a decrease in pancreaticduodenal secretion.More importantly, the resistance to splenic blood flow increases, and intestinal arteriolar flow decreases, in turn reducing lymphatic flow. (3)Surgical therapy typically requires identification of the leak, which can be accomplished by lymphangiography or lymphoscintography.Once the site of extravasation is visualized, a minimally invasive technique such as percutaneous embolization.(4)In cases where conservative management failed, surgical intervention in the form of video-assisted thoracoscopic (VATS) thoracic duct Idiopathic chylothorax is a rare disorder.Massive fluid buildup on the pleural space compromises the respiratory function of a patient.Thoracocentesis to remove the excess fluid was used as a temporary solution until embolization and occlusion of the thoracic duct leak were addressed.Massive chyle leak may lead to weight loss and respiratory distress due to the loss of chyle to the pleural space and its subsequent compression of the lung, affecting its ability to expand.Management