mise à jour du
9 decembre 2004
1975; 233; 6; 536-537
Bilateral chylothorax : a case report following episodes of stretching
Kathryn M. Reilly & Edward Tsou
Pulmonary Division, Georgetown University Medical Center, Washington


CHYLOTHORAX is a relatively rare condition characterized by pleural fluid that has a high concentration of neutral fat and fatty acid but little cholesterol. Bilateral chylothorax is even more unusual. Trauma and tumor are responsible for the majority of the 51 cases of bilateral chylothorax that we were able to find in a search of the literature.
Meade has reported five cases of unilateral chylothorax that he believed were due to hyperextension of the spine with fixation or inherent weakness of the thoracic duct. We describe what we believe is the first reported case of bilateral chylothorax caused by this mechanism.
Report of a Case
A 56-year-old woman was admitted to Georgetown University Hospital on July 9, 1974, for recurrent pleural effusions.
In October 1973, she had experienced the sudden onset of sharp, pleuritic chest pain on the left and swelling above the left clavicle following an episode of vigorous stretching while yawning. Chest x-ray film demonstrated bilateral pleural effusions, greater on the left. Treatment with antibiotics was followed by resolution of her symptoms and clearing of the effusions.
The patient recalled that on the day before the present admission, a similar episode of stretching was followed by swelling in the left supraclavicular fossa, left anterior chest pain, and a dry, nonproductive cough. Bilateral pleural effusions were seen on x-ray films. There was no history of trauma, recent infection, fever, anorexia, or weight loss. Medical history included 20 years of vague arthralgia of the back, knees, and shoulders, three prior episodes of pneumonia, and a two- to three-pack/week cigarette habit for 25 years.
Results of physical examination were normal except for soft-tissue swelling and tenderness in the left supraclavicular fossa, as well as flatness of the percussion note and decreased breath sounds at both lung bases.
The hematocrit reading was 33% and white blood cell (WBC) count was 5,600/cu mm, with a normal differential cell count. The Westergren sedimentation rate was 15 mm/hr. Results of urinalysis, and values for glucose, blood urea nitrogen, amylase, electrolytes, calcium, phosphorous, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, alkaline phosphatase, and bilirubin were normal. Lupus erythematosus preparation, VDRL test, and tests for cold agglutinins were negative. The fluorescent antinuclear antibody test was weakly positive. The complement level was within normal limits.
Initial chest x-ray film disclosed a moderate amount of fluid in both pleural cavities. Bilateral thoracentesis yielded creamy, milky-white fluid. Fluid analysis showed a red blood cell count of 211/cu mm, a WBC count of 1,215/cu mm, with 22 polymorphonuclear leukocytes, 14 lymphocytes, and 64 unidentified mononuclear cells. The fluid cholesterol level of 117 mg/100 ml, with a serum cholesterol value of 171 mg/100 ml, and a positive result on a preparation stained with Sudan IV for fat, confirmed the chylous nature of the fluid. Studies on cells of the fluid and the pleural biopsy specimen showed no neoplasm, and there was no growth of bacteria, fungi, or acid-fast bacilli. Degenerative changes in the cervical, thoracic, and lumbar regions were seen on x-ray films. Mediastinal tomograms, intravenous pyelogram, and scans with gallium citrate Ga 67 were normal. A lung scan did not suggest pulmonary emboli. Bilateral pedal lymphangiograms were obtained on the tenth hospital day, at which time the patient was asymptomatic with only slight blunting of the left costophrenic angle on chest x-ray film. The lymph nodes and thoracic duct were completely normal.
The patient was discharged asymptomatic to be observed by her private physician.
Injury to the thoracic duct below the T-5 level results in a right-sided chylothorax, while damage to the thoracic duet above T-5 leads to a leftsided chylous effusion, The thoracic duct usually crosses from the right to the left side of the thorax at the T3-6 level, and injury to the vessel at this point would be expected to result in spillage of chyle into both pleural cavities. Bilateral chylothorax was discovered in our patient after a second episode of bilateral pleural effusion following stretching. Regrettably, the chylous nature of the fluid was not confirmed after the first episode, but the fluid was probably chylous in the first episode as well as the last since there was a similarity in signs and symptoms on admission, subsequent findings, and in the course of the effusions. We postulate that sudden hyperextension of the spine during yawning resulted in injury to a fixed or inherently weak thoracic duct with leakage of chyle into both pleural cavities, followed by healing of the duct and resorption of the chylous effusions.