History of Present Illness
A 62-year-old Caucasian woman experienced subacute onset of dyspnea. Chest radiography showed the presence of massive right pleural effusion ( Fig. 7.1 ). Therefore she was referred to the pulmonology department.
Past Medical History
The patient had a history of indolent follicular lymphoma with multiple thoracic and abdominal lesions. She had no history of smoking or alcohol abuse, and her previous medical history was otherwise unremarkable.
The patient underwent radiotherapy and first-line chemoimmunotherapy with the rituximab, cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin (vincristine), and prednisone (R-CHOP) regimen for 4 weeks. Subsequent 18 F- fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT), performed for restaging purposes, showed the persistence of intense uptake (maximum standard uptake value [SUV max ] 10.7) at the level of the left supraclavicular fossa and in several abdominal lymph nodes ( Fig. 7.2 , A and B ). Consequently the treatment was continued. There was no evidence of pleural effusion at that time (1 month before the current presentation).
Physical Examination and Early Clinical Findings
At the time of admission, the patient was afebrile, oxygen saturation (SpO 2 ), measured with pulse oximetry, was 95% on room air, heart rate was 92 beats/minute, and blood pressure 120/70 mm Hg.
Physical examination revealed a marked reduction in breath sounds and the presence of tactile fremitus and dullness to percussion in almost all of the right pulmonary field.
Chest ultrasonography showed anechoic right pleural effusion without any significant septation ( Fig. 7.3 ). Routine blood tests showed moderate leukocytosis (white blood cell [WBC] count 14,550/mm 3 ) and a normal differential count. Electrolyte concentration and the results of the liver and kidney function tests were normal.
Clinical Course
An ultrasound-guided small-bore chest drain (12-French [Fr]) was placed, and about 1900 mL of cloudy pleural, nonmalodorous fluid was evacuated ( Fig. 7.4 ). The procedure was well tolerated, and the pleural fluid was sent to the laboratory for analysis.
Chemical analysis of the pleural fluid revealed the following: pH 7.42, glucose 43 mg/dL, triglyceride 728 mg/dL, and cholesterol 70 mg/dL. Pleural fluid WBC count showed 78% of lymphocytes.
These findings confirmed the diagnosis of chylothorax. Conservative treatment, consisting of total parenteral nutrition and subcutaneous administration of octreotide (at a dose of 100 μg every 8 hours for 3 days and subsequently titrated up to 200 μg every 8 hours, over a 6-day period), was started. Chest CT showed small residual right-sided pleural effusion but no lung parenchymal involvement ( Fig. 7.5 ). In the subsequent 10 days, the amount of drained fluid remarkably decreased (from 1.2 L/day to 0.8 L/day), although it persisted. The macroscopic and physicochemical characteristics were consistent with the persistence of chylothorax.
