Chronic Shortness of Breath and Chylothorax Haas J., MD and Engel L.S., MD Department of Internal Medicine, LSU Health Sciences Center New Orleans, LA

Case Report CASE: At the time of admit, physical exam revealed bibasilar DISCUSSION: crackles, dullness to percussion and 3+ pitting edema of the A 76 y/o gentleman with a lower extremities. Initial laboratory data demonstrated a The patient’s findings were history bladder cancer (status normocytic anemia, a D dimer of 515, and a BNP of 130. consistent with a chylothorax. The post chemotherapy and Urinalysis showed mild proteinuria of 30mg/dL. A blood gas differential diagnosis for a lipid transurethral resection), revealed an elevated A-a gradient with a pH of 7.35, PaCO2 of effusion, classically described as a coronary artery disease (status 55, PaO2 of 86. CXR showed bilateral pleural effusions. A CT “milky pleural effusion”, includes post CABG years prior), and scan ruled out pulmonary embolism but revealed extensive both a chylothorax and a COPD presented to the axillary, retroperitoneal, and mediastinal adenopathy. A cholesterol effusion. Gross emergency department with five thoracentesis removed 1.5 liters of “milky effusion” which was appearance of the fluid is not a months of progressive cough exudative with a predominance of lymphocytes, total sensitive diagnostic criterion for a and dyspnea. A chest x-ray cholesterol level of 71mg/dL, a triglyceride level of 266 mg/dL, lipid effusion. The pleural fluid revealed a left sided pleural CEA 4.6, lipase 21, and negative cytology. An anemia workup triglyceride content appears to be effusion which was drained and revealed iron deficiency anemia and although colonoscopy the most helpful measurement in found to be negative for failed to reveal a source of bleeding, multiple randomly differentiating a chylothorax from a malignancy. A diagnosis of arranged 10mm nodules lining the colon were noted: Biopsies cholesterol effusion. In a non- costochondritis and worsening demonstrated atypical lymphoid infiltrates which were later fasting patient, a pleural fluid COPD was suggested. Despite identified as mantle cell lymphoma. triglyceride level greater than further therapy for COPD, the 110mg/dL strongly supports the patient did not improve and he CAUSES OF CHYLOTHORAX diagnosis of a chylothorax but the began to develop bilateral lower . Trauma presence of chylomicrons extremity swelling. One day . Malignancy confirms the diagnosis. Once a prior to admission, the patient . Benign tumors of the thoracic duct chylothorax is identified, the had a repeat cystoscopy for . Tuberculosis etiology should be sought. bladder cancer surveillance and . Fungal disease REFERNCES: visual findings suggested a . Filariasis Light, R.W. Pleural effusions. Med Clin North Am. 2011 Nov;95(6):1055-70. recurrence of bladder cancer. . VenousThrombosis Huggins, J.T. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med. 2010 Dec;31(6):743-50.