A Large Non-Traumatic Chylothorax Leading to Acute Respirato
An 82 year-old man was transferred from a skilled nursing facility for worsening shortness of breath of several days duration. He was found to be in hypoxic acute respiratory failure and required intubation and mechanical ventilation. There was no history of fever, hemoptysis, weight loss or other constitutional symptoms. His past medical history was remarkable for diabetes mellitus, hypertension, cardiac pacemaker, hypothyroidism, dementia and chronic kidney disease. He was a nonsmoker and had no recent surgery or trauma. He was born in New York and there was no history of travel. His PPD status was negative. He was ambulatory with assistance at the SNF.
On examination in the ICU, the patient was orally intubated and sedated. He was afebrile with normal vital signs. Blood pressure ranged from 110/60 mmHg to 130/80 mmHg. There was no clubbing or lymphadenopathy. Lung exam revealed decreased breath sounds on the right side of the chest. Cardiac exam revealed a regular rate and rhythm with a soft systolic murmur Grade II/VI at the apex. No hepatomegaly or ascites was identified. Lower extremity 1+ pitting edema was present. The rest of the exam was unremarkable.
Laboratory findings included a hemoglobin level of 14.4 g/dl, white cell count 8 k/ul, mildly elevated creatinine of 1.8 mg/dl. (Reference level 0.6-1.1 mg/dl), ProBNP-768pg/ml., PaO2 was 85 mm Hg on FiO2 of 40%. Thyroid function test, serum lactate dehydrogenase (LDH), amylase, angiotensin converting enzyme levels and cardiac markers were all normal. The chest roentgenogram (CXR) on admission revealed a large right pleural effusion....