Minimal Lymphatic Leakage in an Infant With Chylothorax Detected by Lymphoscintigraphy SPECT/CT

Abstract

A 7-month-old girl with history of persistent left chylous pleural effusion was referred for lymphoscintigraphy. A previous chest computed tomography (CT) scan demonstrated a small to moderate-sized left pleural effusion but could not identify the lymphatic leakage site. Lymphoscintigraphy using filtered 99m Tc sulfur colloid showed minimal focal activity in the lower chest. A correlative single-photon emission computed tomography (SPECT)/CT localized this activity to distal paraesophageal region, being highly suggestive of the site of lymphatic leakage. Subsequent lymphangiography confirmed these findings, revealing an abnormal lymphatic branch at the level of T10 and T11 vertebrae with retrocrural extravasation toward the left hemithorax. Thoracic duct embolization was accomplished at and proximal to the site of chyle leak using a platinum coil and n-Butyl cyanoacrylate glue. The patient was followed up for .24 months and demonstrated no recurrence of pleural effusion. No ascites or other complications related to the procedure were noted. The case demonstrates that 99m Tc sulfur colloid lymphoscintigraphy SPECT/CT can be a useful modality for detecting the chyle leakage site in children with chylothorax even when the amount of leakage is minimal.

Chylothorax and chylous as

“…Chylothorax was confirmed in n = 9 scintigraphies (▶ Tab. 2: patients # 4, 5,9,10,11,15,16,21) and chylous ascites in n = 5 scintigraphies (▶ Tab. 2: patients # 1, 3,14,19,22).…”

“…In planar lymphoscintigraphy, the inherent lack of detailed spatial and anatomical information can lead to misinterpretation of tracer accumulation, such as misattribution of pathological uptake. Regarding depiction of the general pattern of lymphatic drainage or transport disorders, there have been some preliminary case reports of tomographic acquisitiontechniques such as SPECT/CT for the diagnosis of chylothorax (8,9,15,21). In general, both planar and tomographic acquisi-19, 22, 24).…”

MR Lymphangiography for Focal Disruption of the Thoracic Duct in Chylothorax of an Infant: a Case Report and Literature Review△

“…1 Intranodal lymphangiography requires general anesthesia to ensure complete immobility for intranodal injection and following CT scan to delineate the lymphatic vessels. Its application in children is limited for the slow anesthetic drug injection rate in children and radiation exposure.…”

“…Its application in children is limited for the slow anesthetic drug injection rate in children and radiation exposure. Single-photon emission computed tomography/CT (SPECT/CT) 1 and near-infrared fluorescence (NIRF) lymphatic imaging 2 are also useful for detecting focal thoracic duct damage, but they are timeconsuming, only provide limited resolution, and require special equipment that is not widely available.…”

Effective method of evaluating infantile chylothorax

“…The procedure has a conventional and an intranodal variant, representing the different routes for administering the contrast medium into the peripheral lymph vessels and lymph nodes, respectively. Although lymphoscintigraphy is known to have the same accuracy as lymphangiography when combined with single‐photon emission CT, the necessary equipment is not always available in some institutions. For the pediatric population, intranodal lymphangiography reportedly has some advantages over conventional lymphangiography because the lymphatic vessels are much smaller than the lymph nodes in this population .…”