Yellow nail syndrome with chylothorax after coronary artery bypass grafting

Abstract

BackgroundYellow nail syndrome is a rare condition considered secondary to functional anomalies of lymphatic drainage. Yellow nail syndrome is diagnosed through the triad of intrathoracic findings (30% being pleural effusions), nail discoloration, and lymphedema, with any two features sufficient for diagnosis. We report the second case of post-operative yellow nail syndrome.Case presentationAfter coronary artery bypass grafting, our patient presented with chylothorax on post-operative day 13 and yellow toenail discoloration on post-operative day 28, diagnosing yellow nail syndrome. Initial conservative management with pigtail catheter drainage and low-fat diet with medium-chain triglycerides reduced chylous drainage from 350 mL/day on post-operative day 14 to < 100 mL/day on post-operative day 17. However, by post-operative day 18, drainage returned to 350 mL/day that persisted despite attempts to readjust the catheter position, replacement of catheter with chest tube, and transition to total parenteral nutrition and octreotide while nil per os. Lymphangiogram on post-operative day 32 did not identify the thoracic duct or cisterna chyli, precluding embolization. Talc and doxycycline pleurodeses performed on post-operative days 33 and 38, respectively, resolved his chylothorax and nail discoloration.ConclusionsBoth yellow nail syndrome and chylothorax as a complication of coronary artery bypass grafting are rare entities. The proposed mechanism of post-operative chylothorax is iatrogenic injury to thoracic duct or collateral lymphatic vessels. Diagnosing yellow nail syndrome in patients with post-operative chylothorax (through co-existing yellow nail discoloration and/or lymphedema) may suggest predisposition to impaired lymphatic drainage, portending a difficult recovery and potentially indicating need for surgical management.

Yellow nail syndrome with massive chylothorax after esophagectomy: A case report

“…In patients with YNS, the functional impairment of lymphatic drainage can be associated with lymphedema, pleural effusion, or nail discoloration [ 2 ]. The conditions associated with YNS, including lymphatic impairment, can constitute secondary insults causing functionally anomalous lymphatics, presenting clinically as intrathoracic findings, nail changes, and/or edema [ [5] , [7] ]. Another trigger that causes functionally anomalous lymphatics to manifest clinically as YNS may be the traumatic disruption of lymphatic vessels [ 5 ].…”

“…The conditions associated with YNS, including lymphatic impairment, can constitute secondary insults causing functionally anomalous lymphatics, presenting clinically as intrathoracic findings, nail changes, and/or edema [ [5] , [7] ]. Another trigger that causes functionally anomalous lymphatics to manifest clinically as YNS may be the traumatic disruption of lymphatic vessels [ 5 ]. Intraoperative damage to the thoracic duct or other lymphatic tributaries may overwhelm the lymphatic network, causing accumulation of chyle in the pleural space where it manifests as chylothorax, while in the lower extremity soft tissues it manifests as yellow nails [ 5 ].…”

“…Another trigger that causes functionally anomalous lymphatics to manifest clinically as YNS may be the traumatic disruption of lymphatic vessels [ 5 ]. Intraoperative damage to the thoracic duct or other lymphatic tributaries may overwhelm the lymphatic network, causing accumulation of chyle in the pleural space where it manifests as chylothorax, while in the lower extremity soft tissues it manifests as yellow nails [ 5 ].…”

“…The cause of previously reported cases of pleural effusion after thoracic surgery could be related to YNS. The four previously reported cases of postoperative YNS all followed cardiac surgery: three were coronary artery bypass graft surgeries and one was a mitral valve replacement ( Table 2 ) [ [3] , [4] , [5] , [6] ]. The age of the patients was 60 years or older in all but one case.…”

“…Although the etiology of YNS remains unknown, lymphatic impairment is often involved [ 2 ]. Only a few cases of YNS that became apparent after surgery have been reported; however, neither the clinical features nor the course were clear in those cases [ [3] , [4] , [5] , [6] ]. Herein, we present a case of YNS that presented as massive chylothorax and chylous ascites after esophagectomy, and was resolved using conservative treatment without pleurodesis or the need for surgery.…”