Two Cases of Congenital Chylethorax: A Successful Story of Medical Management

Abstract

Congenital chylothorax (CC) is one of the most common causes of pleural effusions in neonates. Associated ipsilateral pulmonary aplasia in CC results in neonatal respiratory distress. Here, we report 2 cases of CC who were managed in the Teaching Hospital Karapitiya, Sri Lanka, between 2017 and 2019. Both babies were males who presented with respiratory distress within a few hours of birth. Their antenatal ultrasound scans failed to detect CC. Chest radiographs showed left-sided pleural effusions. Pleural fluid was milky yellowish suggestive of chylothorax, and the analysis revealed elevated triglycerides, high lymphocyte counts, and low cholesterol levels compatible with CC. They were managed in the neonatal intensive care unit and kept nil by mouth for initial 48 hours. Intravenous octeotride infusion was started on day one and was continued for 7 and 10 days, respectively. The maximum dose of octeotride was 2 μg/kg/hour. Both babies needed intercostal tube placement for 5 and 6 days, respectively. None of them required invasive ventilation. They were started on a medium-chain fatty acid formula, which was continued for about one week. Both babies were commenced on breast milk by day 7 of life and continued with exclusive breastfeeding. Within two weeks, they were discharged home and followed up in the paediatric respiratory clinic for another year. None of them was found to have long-term respiratory complications during the follow-up.

Chylothorax: Approaches to Diagnosis and Treatment

“…Because of the patient's acute presentation, pseudo-chylothorax was deemed implausible despite being a primary differential diagnosis under "milky" effusions. The pleural fluid's low cholesterol levels further ruled it out (Kankananarachchi et al, 2021). The presence of chylomicrons can be confirmed by the elevated fluid triglyceride levels above the established cut-off limit of 1.24 mmol/L (110mg/dL) or by the gold standard lipoprotein electrophoresis (Rocha et al, 2021;Neumann et al, 2020;Justice et al, 2018).…”

“…Nonetheless, the success rate of thoracic duct ligation (up to90%) is higher than that of embolization (peaking at75%), provided that both procedures are carried out correctly. The morbidity and death rates between surgery (40%) and radiological treatments (0% -2%) were shown to differ significantly, even with the higher efficacy (Chai et al, 2019;Kankananarachchi et al, 2021). However, considering that most studies also included many patients with postoperative chylothorax, the statistics should only serve as guidance (Yee et al, 2018).…”

“…The primary causes of the elevated mortality are congestive heart failure and pulmonary hypoplasia (Healy et al, 2017). Neonatal chylothorax has a high mortality rate of 20% to 60% despite the availability of medicinal and surgical therapy options, particularly when combined with concomitant comorbidities (Kankananarachchi et al, 2021).…”