Use of intravenous immunoglobulins as an adjunct in the conservative management of chylothorax

Abstract

Two children who developed chylothorax after surgery for congenital heart disease are presented. The conservative management of chylothorax is reviewed and the use of immunoglobulins in the treatment of sepsis is discussed. One patient survived.

Chylothorax in Infants and Children

“…162 In 2 children who developed chylothorax after surgery for congenital heart disease, intravenous immunoglobulin G was given prophylactically, after the development of the chylothorax or early in the course of septicemia. 160 In a later study of 8 children with hypogammaglobulinemia and lymphopenia attributable to chylothorax, intravenous immunoglobulin G administration did not lead to discernible protection from infectious complications. 161 …”

“…157 Chylothorax leads to hypogammaglobulinemia and lymphopenia. [158][159][160][161][162] In 16 children who developed chylothoraces after cardiac surgery, there were decreases in the absolute numbers of B lymphocytes (CD19+), T lymphocytes (CD3+), helper T-cells (CD4+), and suppressor/cytotoxic T-cells (CD8+), but a normal CD4+:CD8+ ratio. 159 The absolute number of natural killer cells (CD16+) and metabolic activity of polymorphonuclear leukocytes was normal.…”

Should intravenous immunoglobulin be given to patients with postoperative chylothorax?*

“…Although IVIg is not approved for postoperative secondary immunodeficiency, there is category IIIC evidence that it might be beneficial in the setting of postoperative sepsis (17). Prior to the study in this issue of Pediatric Critical Care Medicine, the only other reports describing the use of IVIg in postoperative chylothorax are small case series of two (18) and three (19) patients. Unfortunately, the study by Dr. Hoskote et al is likely underpowered to determine whether IVIg offers any therapeutic benefit in reducing postoperative sepsis in pediatric cardiac surgery patients.…”

Intravenous immunoglobulin for prophylaxis and therapy of sepsis

“…Patient recruitment of the ESSICS study has ended, and the results are awaited. • Case reports: The incidence of chylothorax after cardiothoracic procedures for congenital anomalies ranges from 0.5 to 2% [45]. It is a serious condition that can result in antibody depletion, lymphocytopenia, protein and caloric malnutrition, electrolyte abnormalities, and an increased risk of generalized infection.…”

“…It is a serious condition that can result in antibody depletion, lymphocytopenia, protein and caloric malnutrition, electrolyte abnormalities, and an increased risk of generalized infection. Prophylactic IVIgG, with doses adjusted to achieve serum IgG levels of more than 750 mg/dL and therapeutic doses of IVIgG in case of sepsis development may help handle this serious operative complication [45]. • Fulminant myocarditis and acute cardiomyopathy of viral, immunogenic, or genetic origin can lead to cardiogenic shock with consecutive multiple organ dysfunction syndrome and sepsis.…”