Our case highlights the importance of suspecting in community acquired meningitis.

INTRODUCTION: Only 0.5 to 1% of cirrhotic patients has chylous ascites (CA). CA is a rare form of ascites with milky peritoneal fluid that is rich in triglycerides. One study showed that the incidence is approximately 1/20,000 admissions at a university hospital over a 20 year period. Here, we report a case of atraumatic CA found in a cirrhotic patient. CASE DESCRIPTION/METHODS: A 66 year old man with cirrhosis secondary to alcohol abuse and hepatitis C virus, presented with marked abdominal distention and abdominal pain. On examination, the abdomen was soft, diffusely tender, distended with shifting dullness. Laboratory findings showed anemia, leukocytosis, normal AST, ALT, lipase and INR ratio. Paracentesis was performed and showed milky fluid. Ascites fluid analysis revealed leukocytosis with increased neutrophil count, triglyceride of 284 mg/dl and negative adenosine deaminase level and cytology. The results were consistent with spontaneous bacterial peritonitis and antibiotics was started. However, he deteriorated with intractable vomiting and was found to have high grade small bowel obstruction from CT imaging. He was taken to the OR for laparotomy but continued to deteriorate and expired. DISCUSSION: The most common causes of atraumatic chylous ascites are lymphatic anomalies (32%), malignancy (17%), cirrhosis (11%), Mycobacterium (15%), and a variety of uncommon causes (21%). Our patient had grade 3 ascites by International Ascites Club Grading system, cirrhotic liver with portal hypertension and high grade small bowel obstruction. All of those factors increased the pressure on the intestinal lymphatic system leading to CA. Paracentesis showing triglycerides above 200 mg/dl gives the diagnosis. Management consists of treating the underlying etiology. Pharmacologic treatment with Orlistat and octreotide were reported to be effective in CA. Transjugular intrahepatic portosystemic shunt and peritoneovenous shunting have been used in refractory cases. However, our patient had sepsis from spontaneous bacterial peritonitis with Child Pugh class C, and high grade small bowel obstruction which excluded him from the insertion of shunts. Repeated large-volume paracentesis is a reasonable option for patients who have end-stage disease not amenable to medical or surgical treatment. It is imperative to realize the critical condition in patients with CA as the one year mortality rate is high (69%) and appropriate studies should be done immediately to find and treat the underlying etiology.