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An uncommon therapeutic option for a challenging cause of pleural effusion

Linh Le Tuan, Cuong Nguyen Ngoc, Hung Tran Viet, Hoan Le, François Pons, Delphine Natali
Breathe 2019 15: e69-e76; DOI: 10.1183/20734735.0014-2019
Linh Le Tuan
1Radiology Dept, Hanoi Medical University Hospital, Hanoi, Vietnam
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Cuong Nguyen Ngoc
1Radiology Dept, Hanoi Medical University Hospital, Hanoi, Vietnam
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Hung Tran Viet
1Radiology Dept, Hanoi Medical University Hospital, Hanoi, Vietnam
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Hoan Le
2Respiratory Medicine Dept, Hanoi Medical University Hospital, Hanoi, Vietnam
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François Pons
3Visceral and Thoracic Surgery Dept, Hanoi French Hospital, Hanoi, Vietnam
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Delphine Natali
4Respiratory Medicine Dept, Hanoi French Hospital, Hanoi, Vietnam
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  • For correspondence: delphinenatali@gmail.com
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Figures

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  • Figure 1
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    Figure 1

    a) Chest radiograph and b) CT scan of the thorax in November 2018, showing a remaining mild right pleural effusion with an 800 mL daily output, despite 2 months of adequate chest tube drainage and a high-protein and low-fat diet.

  • Figure 2
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    Figure 2

    Intranodal lymphangiography. a, b) Cisterna chyli are not seen. Tiny lymphatic vessels are going up (dashed arrows), most visible around the right kidney (full arrow). c, d) no lymphatic vessels are seen at the thoracic level.

  • Figure 3
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    Figure 3

    CT scan of the thorax 24 h after intranodal lymphangiography. Lymphatic vessels a) around the right infero-­posterior parietal pleura (black arrows) and b) around the inferior vena cava (white arrows).

  • Figure 4
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    Figure 4

    Percutaneous embolisation of lymphatic vessels. a) The 22G needle (Chiba, Cook Company, USA) is inserted percutaneously under CT guidance (arrows) into the lymphatic vessel, which was already opacified by lymphangiography. b) Aspiration of lymph in the syringe (arrow) confirms that the tip of needle is within the lymphatic vessel. c) Absolute ethanol is injected slowly through the needle into the lymphatic vessel until the patient feels pain, indicating that the ethanol has reached the pleural space. For this procedure, a total of 8 mL absolute ethanol was injected.

  • Figure 5
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    Figure 5

    CT scan of the thorax without contrast. a) CT scan of the thorax in November 2018, before sclerotherapy showing mild right pleural effusion. b) CT scan of the thorax in January 2019, 2 months after sclerotherapy showing no recurrence of right pleural effusion.

  • Figure 6
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    Figure 6

    Thoracic duct anatomy and different routes of access for sclerotherapy. a) Simplified thoracic duct anatomy. b) Different routes of access to perform sclerotherapy for chylo­thorax: 1) transabdominal thoracic duct embolisation by catheterisation of the thoracic duct via the cisterna chyli; 2) retrograde transvenous embolisation of the thoracic duct through the ­lymphovenous junction; and 3) direct embolisation of the abnormal lymphatic vessel.

Tables

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  • Table 1

    Blood tests

    TestResult in patientNormal values
    White blood cells x109 L−15.474–10
    Haemoglobin g·dL−113.312.5–17.5
    Platelets x109 L−1233150–450
    Prothrombin %8270–140
    Proteins g·L−163.466–87
    Albumin g·L−12735–52
    Sodium mmol·L−1131136–145
    Potassium mmol·L−14.13.5–4.5
    Chlorine mmol·L−19598–107
    Creatinine μmol·L−18162–106
    ASAT U·L−127<40
    ALAT U·L−136<41
    HIV (Elisa test)Negative
    HCV antibodiesNegative
    HBV antigen HbSPositive (378 COI)<0.9
    Filariasis antibodiesNegative

    ASAT: aspartate amino transferase; ALAT: alanine amino transferase; HCV: hepatitis C; HBV: hepatitis B; COI: cut off index.

    • Table 2

      Main causes of chylothorax

      Traumatic
      •  Iatrogenic

      • Thoracic and cervical surgery

      • Oesophagus surgery

      • Retroperitoneal surgery

      • Cervical vascular catherisation

      • Thoracic irradiation

      •  Non-iatrogenic

      • Penetrant and non-penetrant trauma

      • Increased thoracic pressure (peripartum, heavy cough or vomiting)

      • Nontraumatic

       Malignant
      • Lymphoma, chronic lymphocytic leukaemia, multiple myeloma

      • Lung cancer, oesophagus cancer, mediastinal metastasis of other cancers

      • Kaposi sarcoma

       Non-malignant obstruction of the thoracic duct or aberrant lymphatic flow
      • Sarcoidosis

      • Amyloidosis

      • Superior vena cava thrombosis

      • Lymphangioleiomyomatosis

      • Castleman disease

      • Goiter

      • Constrictive pericarditis

      • Yellow-nail syndrome

      • Chylous ascites

       Congenital
      • Turner syndrome

      • Noonan syndrome

       Infectious diseases
      • Tuberculosis

      • Histoplasmosis

      • Mediastinitis

      • Filariasis

      • Idiopathic

      Idiopathic
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    An uncommon therapeutic option for a challenging cause of pleural effusion
    Linh Le Tuan, Cuong Nguyen Ngoc, Hung Tran Viet, Hoan Le, François Pons, Delphine Natali
    Breathe Jun 2019, 15 (2) e69-e76; DOI: 10.1183/20734735.0014-2019

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    An uncommon therapeutic option for a challenging cause of pleural effusion
    Linh Le Tuan, Cuong Nguyen Ngoc, Hung Tran Viet, Hoan Le, François Pons, Delphine Natali
    Breathe Jun 2019, 15 (2) e69-e76; DOI: 10.1183/20734735.0014-2019
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