Recurrent Chylous Ascites Leading to Transudative Chylothorax Due to Bi-Ventricular Heart Failure

Abstract

Chylothorax is a pleural effusion of >110 mg/dL of triglycerides with a milky appearance with transudative being rare. In this article, we present a case of transudative chylothorax with concurrent chylous ascites that is secondary to congestive heart failure (CHF). A 70-year-old male with CHF with ejection fraction of 10%, coronary artery disease status post coronary artery bypass graft, sleep apnea, chronic kidney disease stage 3, and chronic obstructive pulmonary disease presented with worsening abdominal distention, shortness of breath, and increased lower extremities edema. He denied any cough or fever but had orthopnea and paroxysmal nocturnal dyspnea. He requires monthly paracentesis with drainage of 5 to 9 L each time. On physical examination, he had crackles bilaterally with no wheezes or jugular venous distension. His cardiac examination was unremarkable. He did have abdominal distension with dullness to percussion and a positive fluid wave. There was +2 bilateral pitting edema of lower extremities. He had a diagnostic paracentesis where 9.2 L of cloudy milky fluid was drained and therapeutic thoracentesis where 1.1 L of milky fluid was drained. Pleural fluid for triglycerides was 280. His peritoneal fluid had triglycerides of 671 confirming chylous ascites. CHF can lead to chylous ascites due to the increased lymph production in the abdomen, which flows to the thoracic duct. Due to the stiffness at the lymphatic junction, there is high pressure for less flow. The diaphragm plays a role allowing the chylous ascites to be absorb into the thorax.

Chylothorax in the Setting of Lung Malignancy

“…In a retrospective review of 7 transudative chylous effusions, Agrawal et al 6 noted all of the cases to be associated with both chyle leakage and a coexisting process with the potential for causing pleural effusions by itself, such as congestive heart failure, superior vena cava obstruction, pulmonary hypertension, nephrotic syndrome, amyloidosis, and ascites. 1 This finding is consistent with our review of the literature, including a case report by Cassandra Do et al, 2 in which they reported the occurrence of a transudative chylothorax secondary to recurrent chylous ascites.…”

“… 1 Chyle contains chylomicrons that transport triglycerides from the intestines to the lymphatic fluid and then eventually to the venous system by the way of the thoracic duct. 2 A triglyceride concentration of greater than 110 mg/dL or the detection of chylomicrons in the pleural fluid is considered diagnostic for chylothorax. 3 In a retrospective study conducted by Maldonado et al, 4 almost half of the cases with chylothorax had a milky-white appearance to the pleural fluid; however, the majority were nonwhite in appearance and variations included serous, serosanguinous, or bloody effusions.…”

Hepatic Chylothorax: An Uncommon Pleural Effusion

“…The transudative chylothoraces are found to be associated with liver cirrhosis, nephrotic syndrome, superior vena caval thrombosis and congestive heart failure. 3 , 10 , 11 Literature reviews by Diaz-Guzman et al 12 and Agrawal et al 9 have identified liver cirrhosis as the most common causes of transudative chylothorax.…”

Disseminated tuberculosis presenting as bilateral chylothorax: A case report

“… 6 Although traumatic causes are the most common cause of chylothorax, they can rarely occur in non-traumatic causes such as malignancy, sarcoidosis, congestive heart failure, cirrhosis, and diseases of lymph vessels. 7 – 9 Any disease that can cause mediastinal lymphadenopathy can compress the thoracic duct, causing chyle to extravasate into the pleural space. 10 Mortality due to chylothorax has been reduced from 50℅, which was recorded in 1948, and is assumed to be much less currently due to aggressive management and early diagnosis.…”