Chylothorax in Paracoccidioidomycosis

Abstract

SUMMARYA previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions.

Thoracic duct lymphangioma and chylous ascites in a 24-year-old female

“…3 Chylous ascites is also rare, with the incidence of hospital admissions estimated at approximately 1: 20,000 up to 1: 180,000, according to international studies. 5,6 This is characterized by the accumulation of milky fluid in the abdominal cavity with a high level of triglycerides. The most common causes of ascites in the West are liver cirrhosis and malignancies in more than 60% of cases; less common are tuberculosis, filariasis, paracoccidioidomycosis, congenital, inflammatory, postoperative, and traumatic.…”

“…The most common causes of ascites in the West are liver cirrhosis and malignancies in more than 60% of cases; less common are tuberculosis, filariasis, paracoccidioidomycosis, congenital, inflammatory, postoperative, and traumatic. [4][5][6][7]9 This ascites can manifest with nausea, anorexia, early satiety, weight loss, abdominal distension, nonspecific abdominal pain, dyspnea, fever, and night sweats. 6 The definitive diagnosis is made by paracentesis, with a milkylooking liquid and triglyceride dosage higher than 200 mg/dl.…”

“…Radiological studies such as CT and MRI are useful in identifying the presence of free fluid in the cavity, pathological masses, and lymph node enlargement; while lymphangiography and lymphoscintigraphy can help to detect dilation of lymphatic vessels, fistulas, and the permeability of the thoracic duct. 5 Treatment of chyloperitoneum can be either conservative or surgical; the latter is indicated when there is no improvement with conservative treatment in two to three weeks. 8 Cases that maintain drainage volumes above 1000 mL per day for more than five days are considered non-responsive.…”

“…[4][5][6][7] As in the present case, the mechanism of ascites might be the result of a direct loss of chylous fluid through a lymphatic-peritoneal fistula, associated with the portal or non-portal etiologies, including either congenital malformations or acquired conditions. [4][5][6][7] We report the case of a woman with thoracic duct lymphangioma, which was investigated through chylous ascites that the patient initially presented, with a brief review of the clinical aspects, diagnosis, and treatment of this pathology. The aim of the study is to report the case of a young patient with chylous ascites due to thoracic duct lymphangioma who was treated conservatively with octreotide and a low-fat diet with medium-chain triglycerides (TCM).…”

Chylous ascites secondary to Hodgkin’s lymphoma in a HIV/aids patient: case report and literature review

“…CA is a rare condition (1:20,000 admissions in general hospital, but 1:2,248 HIV hospital interments) 7 first described in 1691, which has a vast differential diagnosis, 15 such as trauma, post abdominal surgery, liver cirrhosis, cancer, infectious (tuberculosis, Mycobacterium avium complex, filariasis, paracoccidioidomycosis), 16 pancreatic, yellownail syndrome, lymphatic malformation, among others. Although lymphoma is frequently remembered in differential diagnosis of CA (expected frequency of 33-50% of all cases), recent review cites frequency of 8% among adult cases, 15 and in HIV population this frequency seems to be even lower.…”