Bilateral Chylothorax due to Brachiocephalic Vein Thrombosis in Relapsing Nephrotic Syndrome

Autor: Pankaj Malik, Priyanka Ameta, Anuj Dhyani, Lakhan Poswal
Rok vydání: 2015
Předmět:
Zdroj: The Indian Journal of Pediatrics. 82:1181-1182
ISSN: 0973-7693
0019-5456
DOI: 10.1007/s12098-015-1769-4
Popis: To the Editor : Chylothorax is a pleural collection of fluid formed by the escape of chyle from the thoracic duct or lymphatics. The most common cause of chylothorax in children is secondary to cardiothoracic surgery [1]. Other causes include trauma, malignancy, tuberculosis and lymphangiomatosis. Approximately 25% of chylothoraxes have no identifiable cause; they are presumed to be secondary to minor trauma. Nephrotic syndrome is not a recognised cause of chylothorax. However, chylous ascitis is a known complication and simultaneous occurrence of chylothorax and chylous ascitis has been reported rarely, which was shown to be due to transdiaphragmatic movement of chylous fluid, caused by negative intrathoracic pressure during inspiration [2, 3]. We describe a patient with nephrotic syndrome who presented with bilateral chylothorax without ascitis. A 9-y-old boy, with history of multiple relapses of nephrotic syndrome during last 7 y, presented with relapse after 3 y of remission. On examination, RR was 38 with significant distress and SpO2 was 84 and 98% without and with oxygen respectively. He was afebrile and had slight tachycardia with normal blood pressure. On respiratory system examination air entry was significantly decreased in inframammary, axillary and infra scapular region bilaterally, with dull note on percussion. Tactile vocal fremitus and vocal resonance were also reduced. CXR revealed bilateral pleural effusion (Fig. 1). Pleural tap showed chylous fluid bilaterally. On investigations urine protein was 4+, serum albumin was 1.2 g/dl, cholesterol level 725.8 mg/dl. Pleural fluid showed triglyceride of 144 mg/dl and cholesterol of 5 mg/dl, suggestive of chylothorax. Child was treated with repeated aspirations for respiratory distress, dietary modifications and steroids for nephrotic syndrome relapse. CTangiography showed filling defect in brachiocephalic vein suggestive of thrombosis (Fig. 2). Heparin and warfarin were started after documentation of normal coagulation profile. The child was discharged after disappearance of anasarca and respiratory distress, on warfarin, steroids and supportive treatment. In this patient, nephrotic syndrome caused hypercoagulable state leading to brachiocephalic vein thrombosis, which could be responsible for chylothorax. Children with nephrotic syndrome are at an increased risk of thromboembolic events. The incidence of this complication in children is 2–5%, which represents a much lower risk than that of adults with nephrotic syndrome. Both arterial and venous thromboses may be seen, including renal vein
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