Case Report

A 40 year-old gentleman was admitted to our hospital with dyspnea and swelling of his face. The patient noticed redness and progressive swelling of his face and also edema of his both arms in the past 2 months. The patient was diagnosed with progressive focal segmental glomerulosclerosis 14 years before presentation resulting in end-stage renal disease requiring hemodialysis. He also had two failed cadaveric renal transplantations 10 years and 1 year before presentation. Multiple central venous accesses were required during past 10 years for hemodialysis. The patient was a life-long non-smoker. Physical examination showed temperature of 97.7°F, blood pressure of 146/85, heart rate of 82 beat/min, and respiratory rate of 20breath/min. Dilated bilateral jugular veins, bilateral edema of upper extremities, dilated chest wall veins and plethoric face were noted on examination. Chest exam revealed decreased breath sounds and dullness to precautions over right hemithorax. Cardiac and abdominal exams were unremarkable. A Doppler ultrasound examination showed thrombosis of bilateral subclavian veins and internal jugular veins with central extension. A chest radiograph showed large right sided pleural effusion. Thoracentesis of right pleural effusion showed cloudy and milky fluid. Analysis of pleural fluid revealed high triglyceride level consistent with chylothorax (triglyceride level > 110 mg/dl). Physical examination did not reveal evidence of lymphoproliferative disorders and magnetic resonance imaging (MRI) of abdomen and computed tomography (CT) scan of chest showed no lymph node enlargement. A lymphangiogram showed normal appearing lymphatic drainage without extravasation. A superior vena cava (SVC) self-expanding 10X42 mm stent was placed and the patient was treated with anticoagulation. The face and arm swelling improved markedly over next 2 weeks. Serial chest radiographs showed slowly resolving right pleural effusion over next 4 weeks (figure1). Repeat analysis of pleural fluid after SVC stent placement and anticoagulation therapy showed clear pleural fluid and decreased triglyceride levels (table1). The chylothorax was most likely secondary to extensive central venous catheter induced-thrombosis of central veins of chest and SVC syndrome.

Chylothorax as a complication of SVC thrombosis and SVC syndrome has been reported in case reports₁, ₂, ₃. Long-term success of endovascular treatment of benign SVC occlusion also has been reported₄. This report presents a case of chylothorax secondary to catheter-induced SVC syndrome that was treated successfully with SVC stent placement and anticoagulation therapy. To the best of my knowledge this is the only reported case that clearly demonstrates resolution of chylothorax after SVC stenting. SVC syndrome secondary to catheter-induced SVC thrombosis should be considered as a cause of chylothorax when appropriate. SVC stent placement with anticoagulation may result in resolution of chylothorax.

Figure 1

Table 1: Pleural fluid analysis results on presentation, on week after SVC stent placement, and 18 days after stent placement on high fat diet.

Figure 2

Figure 1A:Chest radiograph showing SVC stent and large right pleural effusion

Figure 3

Figure 1B: Chest radiograph 4 weeks later showing resolution of right pleural effusion

Correspondence to

Bobbak Vahid, MD Thomas Jefferson University 1015 Chestnut Street, Suite M-100 Philadelphia, PA 19107 Tel: 215 955-6591 Fax: 215 955-0830 Bobbak.vahid@mail.tju.edu