What is wrong?
Our patient had lymphatic fluid draining from the R chest wound. While thoracic duct injury is most often noted in the L chest; there is significant lymphatic drainage on the R as well which can be injured by thoracic surgery or neck dissection. The typical L sided thoracic duct occurs in only 65% of the population due to variations which include multiple thoracic duct branches.
Another cause of chylous effusion is central line placement. Cases have been reported of chylous effusions after IJ placement. In addition to trauma; chylothorax can occur after childbirth, in association with lymphoma (accounts for 70% of non traumatic cases) , sarcoid, thoracic goiters, amyloidosis, filariasis, SVC thrombosis and yellow nail syndrome which is a congenital abnormality of the lymph system.
Injury to the thoracic duct can result in cervical chylous fistula, chylothorax or chylopericardium. Since 2.4 L of chyle is transported through the lymp system every day; a large effusion can rapidly accumulate causing dyspnea. .
The diagnosis is made by sending triglycerides on the fluid and the cell count should be lymphocyte predominant. Both of our patients were diagnosed in the ED by sending triglycerides on the fluid
Conservative management of a lymphatic injury includes low-fat diet, TPN and drainage of the chylothorax. Failing conservative management results in either lymphangiogram with embolization of the leak or thoracic duct ligation surgically.
Our first pt had a lymphangiogram demonstrating leakage of lymph and underwent repair of his subclavian stenosis. The drainage stopped. The second patient was presumed to have chylothorax from malignancy and was referred to oncology.
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