Bilateral Chylothorax as a Unique Presentation of Pancreaticobiliary or Upper Gastrointestinal Cancer

Abstract

Chylothorax presents as exudate with lymphocytic predominance and high triglyceride-low LDH levels, usually due to a traumatic disruption of the thoracic duct, possibly iatrogenic. Other causes include malignancy, sarcoidosis, goiter, AIDS, or tuberculosis. Here we present a case of a 66-year-old male who came in with cough and shortness of breath for few weeks. A week earlier, at an ED visit, he was diagnosed with pneumonia based on CT angiogram of the chest without contrast that showed bilateral pleural effusion and bilateral pulmonary infiltrates. The CT-guided placement of bilateral chest tube drained 1160 cc of creamy yellow fluid on the right and 1200 cc of creamy yellow fluid on the left. CT chest/abdomen/pelvis showed bilateral ground-glass opacities within the lungs and possible bony metastasis. A whole-body bone scan showed multiple bony metastatic lesions throughout the skeleton. IR guided bone biopsy suggested upper GI or pancreaticobiliary cancer. Venous ultrasound with Doppler of left upper extremity showed findings suggestive of a nonocclusive DVT of proximal/mid left subclavian vein which is difficult to compress. Eventually, malignancy-related DVT of the left subclavian/brachiocephalic vein was identified as the possible etiology for the bilateral chylothorax.

Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report

“…Theoretically, our patient should have developed isolated left-sided pleural effusion caused by chyle leakage in the left lung as the drainage system of the right lung mostly does not involve the thoracic duct and the subclavian and jugular veins. However, other case reports have also described bilateral chylothorax with one-sided thrombosis in the upper extremities without thrombosis in the lower part of the central venous system (for example vena cava inferior) [ 7 , 10 , 13 , 17 ]. Another possible explanations of the right-sided pleural effusion in our patient could be the rapid decrease in albumin.…”

Double trouble: Biochemically confirmed bilateral chylothorax with positive pleural fluid cytology due to breast adenocarcinoma

“…Of these 12 pertinent publications ( Table 1 ), only one report [ 7 ] provided biochemical confirmation of bilateral chylothorax, though the PF was negative for malignant cells on both sides. The other 11 articles [ [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] ] described occurrence of bilateral chylothorax but confirmatory PF studies were invariably provided from only one side. Among these 11 cases, cytology was positive for 1 case with a primary gastric adenocarcinoma, 1 case with primary low differentiated adenocarcinoma with signet cells and 2 cases with primary signet ring cell carcinoma.…”