Differential diagnosis and treatment of chylothorax and pseudochylothorax after lung cancer surgery / 中华胸心血管外科杂志

Objective:To explore the differential diagnosis and different treatment methods of chylothorax and pseudochylothorax after lung cancer surgery.Methods:Clinical data of 1 584 surgical patients with non-small cell lung cancer from January 2016 to December 2021 were analyzed, 21 cases of chylothorax and 8 cases of pseudochylothorax were identified and analyzed to compare the differences in pleural fluid chyle test, pleural effusion biochemical values, total cholesterol, triglycerides, total cholesterol/triglyceride ratio, leukocyte count, bacterial culture and treatment.Results:The incidence of chylothorax after lung cancer surgery was 1.3%, and the incidence of pseudochylothorax was 0.5%; 80.9%% of chylothorax on the right side was significantly higher than 19.1% of chylothorax on the left side, and the difference was statistically significant( P<0.05). Pseudochylothorax occurred on the right side(100%). The difference between chylothorax and pseudochylothorax in pleural fluid tests for cholesterol and triglyceride was statistically significant( P<0.05), the leukocyte count was significantly higher in pseudochylothorax than chylothorax, and the difference was statistically significant( P<0.05). The differences in drainage before treatment, postoperative drainage time and postoperative hospitalization time between the two groups were statistically significant( P<0.05). The success rate was 61.9% in 13 cases of chylothorax treated conservatively and 38.1% in 8 cases of thoracic duct clamping; all cases of pseudochylothorax were treated conservatively with a success rate of 100%. Conclusion:In naddition to pleural fluid chyle test and pleural effusion biochemical values, total cholesterol, triglyceride and total cholesterol to triglyceride ratio in pleural fluid should be tested to identify chylothorax and pseudochylothorax, high triglyceride in pleural fluid diagnosed as chylothorax; Pseudochylothorax is diagnosed with a cholesterol/triglyceride ratio >1 in the pleural fluid, pseudochylothorax is usually treated conservatively. Chylothorax is treated conservatively and surgically according to different conditions. If the drainage flow is greater than 800 ml/day for 3 consecutive days or if it causes serious electrolyte disorders, it is recommended to perform thoracoscopic-assisted thoracic duct clamping via right-sided approach.

Chylothorax and Pseudochylothorax.

Classically, both chylothorax and pseudochylothorax present as a pleural effusion with a characteristic milky white appearance to the pleural fluid. Although both are rare causes of pleural effusion, they have distinct etiologies and clinical implications, and as a result require different management strategies. Pleural fluid analysis of cholesterol and triglyceride levels is key to differentiating the 2 entities from one another and then guide the clinician to determine the best next steps in evaluation and management.

[Differential diagnosis of chylothorax in therapeutic practice].

The article is devoted to the differential diagnosis of chylous pleural effusion. The spectrum of traumatic and non-traumatic causes of chylothorax is discussed in detail. Examples of necessary diagnostic measures are given for the accumulation of milky fluid in the pleural cavity in order to verify chylothorax.

Multiple neurofibromas plus fibrosarcoma with familial NF1 pathogenicity: A case report.

BACKGROUND: Neurofibromatosis (NF) is a genetic disease consisting of seven types, of which types 1 to 4 are caused by a dominant autosomal gene mutation; such disease sometimes arises in patients with NF type 1. However, it remains unclear whether the origin of neurofibrosarcoma is directly linked to the incidence of NF type 1, as no reports have been published on this issue. Here, we report a case of NF1-positive multiple neurofibromas with malignant fibrosarcomatous transformation in the pleural cavity. CASE SUMMARY: A 51-year-old male was admitted to our hospital due to fever accompanied by coughing, chest tightness and asthma for more than one month. The preliminary diagnosis was NF type 1, which was pathologically confirmed by a subsequent thoracoabdominal subcutaneous biopsy. The definitive diagnosis was neurofibrosarcoma with a pathogenic NF1 gene. The patient refused surgery and chemoradiotherapy, and died two months later. NF is a genetic disease consisting of seven types, of which types 1 to 4 are caused by a dominant autosomal gene mutation. The case reported belongs to the class of NF1-positive dominant inheritance. Neurofibrosarcoma is a malignant tumor derived from cells surrounding the peripheral nerves. However, due to the lack of previous reports, it remains unclear whether the origin of neurofibrosarcoma is directly linked to the incidence of NF type 1. CONCLUSION: We report the first case of NF1-positive multiple neurofibromas with malignant fibrosarcomatous transformation in the pleural cavity.

Clinical approach and review of causes of a chylothorax.

A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.

Do Bilateral Pleural Effusions Always Have the Same Cause?

A 67-year-old man with a history of seropositive rheumatoid arthritis (RA) was admitted to the Internal Medicine ward for bilateral pleural effusion. Two years before this episode, coinciding with an exacerbation of the RA, he was incidentally diagnosed with asymptomatic left pleural effusion compatible with rheumatoid exudate, which was resolved with a tube thoracostomy. Three weeks before admission, the patient developed asthenia, orthopnoea and progressive dyspnoea. A chest x-ray revealed bilateral pleural effusion occupying the lower third of the left hemithorax and a smaller portion of the right hemithorax along with marked elevation of N-terminal fragment of pro-brain natriuretic peptide levels. The patient was admitted with a diagnosis of left-sided heart failure. Transthoracic echocardiography and cardiac catheterization confirmed the existence of ischaemic cardiomyopathy. After 2 days of diuretic treatment, the right pleural effusion resolved, but the left effusion persisted. A needle thoracentesis was performed, draining 800 ml of milky fluid compatible with rheumatoid pseudochylothorax. LEARNING POINTS: Bilateral pleural effusions nearly always have the same cause, and usually thoracentesis on only one side is needed.Rarely, however, there can be two separate causes: this is known as Contarini's syndrome.

Pseudochylothorax: An unusual mode of revelation of pleural metastasis from solid tumor.

INTRODUCTION: Pseudochylothorax is a rare cause of pleural effusion. Sometimes confounded with chylothorax, firm diagnosis relies on analysis of the pleural liquid: exudative liquid (protein >30 g/L, lactate dehydrogenase >200 UI/L) with a high level of cholesterol (usually >200 mg/dL), low level of triglyceride (usually <110 mg/dL), cholesterol total/triglyceride ratio >1, absence of chylomicron, and in some cases the presence of cholesterol crystals. Pseudochylothorax is secondary to tuberculosis and rheumatoid arthritis in nearly 90% of cases. Its oncologic etiologies are mainly represented by malignant hematologic disorders. METHODS: We report the first case of pseudochylothorax whose cause was the pleural metastasis of an extrathoracic solid tumor in a 61-year-old man with a medical history of oropharynx carcinoma. RESULTS: Computed tomography scan disclosed a left partitioned effusion of high abundance, responsible for a passive atelectasis of the left lower lobe and multiple bilateral pulmonary nodules. A drainage tube was inserted to allow the evacuation of serous liquid; biochemical examination revealed an exudative effusion with pseudochylothorax criteria. Because the daily chest drainage output remained greater than 1 L per day, videothoracoscopy pleural biopsies and talc pleurodesis were performed. Histopathologic examination of the pleural biopsies found a pleural localization of oropharynx carcinoma. CONCLUSION: Because its occurrence is probably underestimated, when pseudochylothorax is diagnosed, oncologic causes should be considered.

Characteristics of patients with pseudochylothorax-a systematic review.

BACKGROUND: Pseudochylothorax (PCT) (cholesterol pleurisy or chyliform effusion) is a cholesterol-rich pleural effusion (PE) that is commonly associated with chronic inflammatory disorders. Nevertheless, the characteristics of patients with PCT are poorly defined. METHODS: A systematic review was performed across two electronic databases searching for studies reporting clinical findings, PE characteristics, and the most effective treatment of PCT. Case descriptions and retrospective studies were included. RESULTS: The review consisted of 62 studies with a total of 104 patients. Median age was 58 years, the male/female ratio was 2.6/1, and in the 88.5% of cases the etiology was tuberculosis (TB) or rheumatoid arthritis (RA). PE was usually unilateral (88%) and occupied greater than one-third of the hemithorax (96.3%). There was no evidence of pleural thickening in 20.6% of patients, and 14 patients had a previous PE. The pleural fluid (PF) was an exudate, usually milky (94%) and with a predominance of lymphocytes (61.1%). The most sensitive tests to establish the diagnosis were the cholesterol/triglycerides ratio (CHOL/TG ratio) >1, and the presence of cholesterol crystals (97.4% and 89.7%, respectively). PF culture for TB was positive in the 34.1% of patients. Favorable outcomes with medical treatment, therapeutic thoracentesis, decortication/pleurectomy, pleurodesis, thoracic drainage and thoracoscopic drainage were achieved in 78.9%, 47.8%, 86.7%, 66.6%, 37.5% and 42.9%, respectively. CONCLUSIONS: PCT is usually tuberculous or rheumatoid, unilateral and the PF is a milky exudate. The presence of cholesterol crystals and a CHOL/TG ratio >1 are the most sensitive test for the diagnosis. The lack of pleural thickening does not rule out PCT. Treatment should be sequential, treating the underlying causes, and assessing the need for interventional techniques.

Chyliform effusion without pleural thickening in a patient with rheumatoid arthritis: A case report.

Pseudochylothorax, also known as chyliform effusion rich in cholesterol crystals, is a rare entity that sometimes occurs in long-standing rheumatoid arthritis (RA) and is usually associated with thickened pleura. There have only been a few case reports in the literature on pseudochylothorax unassociated with pleural thickening and with a short duration of articular symptoms in patients with RA. We report the case of a 70-year-old male patient with a history of RA and heart failure due to severe aortic stenosis, who presented with signs and symptoms of decompensated heart failure due to a moderate right-sided pleural effusion that was consequently proved to be pseudochylothorax unassociated with pleural thickening on chest computed tomography (CT) scan. The patient's outcome was favorable after thoracocentesis was carried out and leflunomide was added to the standard heart failure treatment.

An unusual case of pseudochylothorax.

A 25-year-old male patient presented with right-sided pleuritic chest pain and pain in the ankle. Radiological investigations revealed a right sided pleural effusion, lytic lesion in spine D10 with paravertebral abscess. Pleural fluid analysis showed elevated lactate dehydrogenase, adenosine deaminase, increased triglycerides, cholesterol, and no chylomicrons. Hence, a diagnosis of pseudochylothorax secondary to tuberculosis was made. Pleural fluid was drained by tube thoracostomy, decortication was done to improve the lung function and patient was started on anti-tuberculosis treatment (ATT). Patient improved with ATT. Pseudochylous effusion or chyliform effusions are uncommon. <200 cases has been reported in the international literature. The possibility of tuberculosis has to be considered in diagnosis and treatment of such cases. Here, we present a case of tuberculous pseudochylous effusion.

Surgical treatment of recurrent pseudochylothorax occurring after therapy of tuberculous pleurisy / 영남의대학술지

Pseudochylothorax is an uncommon pleural effusion disease characterized by the presence of cholesterol crystals or high lipid content not resulting from a disrupted thoracic duct. Most of the cases reported so far had been found in patients with long-standing pleural effusion due to a chronic inflammatory disease such as old tuberculous pleurisy or chronic rheumatoid pleurisy. Authors encountered a case of pseudochylothorax in a 45-year-old man who had been treated for tuberculous pleurisy 6 years before his visit to authors' hospital. After that, he had visited the emergency department many times for removal of pleural effusion. The patient's chest X-ray revealed dyspnea and large left-sided pleural effusion. Although a large amount of pleural fluid was removed with a drainage catheter, massive pleural effusion was likely to recur, and the underlying lung was able to fully re-expand. Accordingly, decortication was done, and the patient's symptom was improved without postoperative complications.

Rheumatoid pleural effusion presenting as pseudochylothorax in a patient without previous diagnosis of rheumatoid arthritis.

BACKGROUND: Rheumatoid pleurisy rarely occurs before a diagnosis of rheumatoid arthritis (RA). It is the second leading cause of pseudochylothorax, but there are few reports of RA-associated pseudochylothorax. CASE: A 50-year-old man presented to our hospital with an undiagnosed exudative pleural effusion. In order to obtain a definitive diagnosis, we performed medical thoracoscopy under local anesthesia. The pleural effusion was turbid and was identified as a pseudochylothorax. The parietal pleura was white and slightly thickened with numerous scattered small granules and the pleural biopsy showed an infiltration of inflammatory cells including lymphocytes and plasma cells with a lack of normal mesothelial cells, findings that were highly consistent with rheumatoid pleurisy. Additional laboratory data revealed elevated levels of CCP antibody and rheumatoid factor. During an outpatient visit about 30 days after discharge, the patient complained of polyarthralgia and was diagnosed with RA, resulting in a definitive diagnosis of the pleural effusion as rheumatoid pleurisy. CONCLUSION: We encountered a rare case of a rheumatoid pleural effusion without other symptoms of arthritis, which was identified as a pseudochylothorax by medical thoracoscopy.

A Case of Pseudochylothorax Developed from Chronic Pleural Effusion after Treatment of Tuberculous Pleurisy / 결핵및호흡기질환

A pseudochylothorax, a chyliform pleural effusion, is a rare disease of pleural effusion that contains cholesterol crystals or high lipid content that is not the result of a disrupted thoracic duct. Most of the cases were found in patients with long-standing pleural effusion due to chronic inflammatory disease, such as old tuberculous pleurisy or chronic rheumatoid pleurisy. We experienced a case of pseudochylothorax in a 74-year-old man, who was being treated for pulmonary tuberculosis and pleurisy 10 years ago. The diagnosis was confirmed on pathological study of the pleural effusion, which contained cholesterol crystals having a diagnostic rhomboid appearance.