Patient Case Discussion
Case Summary
Chest X-Ray Findings
This was a case of a 17-year-old male hockey player who presented with shortness of breath. The patient was otherwise healthy and had no recent trauma or medication use. The surgical team interpreted the chest X-ray, which showed a complete whiteout of the right chest with tracheal deviation to the left side. It was noted that the pathology was on the right side, possibly a pleural effusion, and recommended further tests. The moderator asked if a complete lung collapse was possible, but the case prresenter doubted that because of the tracheal deviation. They discussed the possible causes of the effusion, including paraneumonic, blood, cardiac, and chylothorax. The team concluded that the patient was likely hemodynamically stable, because there was no history of trauma.
Chylothorax Diagnosis and Confirmation
The diagnosis and confirmation of chylothorax was discussed, a condition where lymphatic fluid accumulates in the chest. The moderator noted that the fluid's appearance, such as being milky or whitish, can indicate chylothorax. However, he also noted that in some cases, like in a neonate who has not been feeding, the fluid may not appear milky. In such cases, it is important to order a cell differential and count to confirm the diagnosis, as chylothorax typically has more than 90% lymphocytes. Chylothorax is most commonly encountered in the neonatal age group, particularly in NICU patients.
Chylothorax Treatment and Management Discussion
The surgical team discussed the treatment of chylothorax, a condition where lymphatic fluid accumulates in the chest. The moderator outlined three treatment options: (1) conservative management with chest drainage and medication, (2) interventional radiology-guided embolization of the thoracic duct, and (3) surgical intervention. It is important to consider the patient's comfort level and the need for a tailored approach. Also highlighted was the potential complications of chylothorax, including immunological and nutritional issues. The patient in question was initially managed by the pediatric team but was later transitioned to the neurosurgery team, who successfully drained the fluid and discharged the patient.
Pleural Effusion and Chyle Leak Management
The patient's CT scan revealed a large, right-sided pleural effusion causing cardiomediastinal shifting and airway compression, with no evidence of an underlying mass. After initial drainage, the effusion partially resolved but later reaccumulated, possibly because of a cough-induced leak reopening. The patient was readmitted, a chest tube was replaced, and approximately 3.5 liters of chyle were drained. Despite initiating Octreotide and TPN, the drainage output remained significant, prompting discussions about potential IR embolization or surgical intervention for the persistent leak.
Chylothorax Management With Lipiodol and Glue
The team discussed management of a case involving a patient with chylothorax, a condition where lymphatic fluid leaks into the pleural space. An intervention radiologist, explained the procedure of injecting lipiodol into the lymphatic system to identify the leaking channels and then using a microcatheter to inject glue into the thoracic duct to block the leak. The procedure was successful in adults, but in pediatric cases it was repeated because of continued leakage. The team agreed that this procedure should be considered before surgical intervention, as it has significantly changed the landscape of managing refractory cases.