Massive primary chylopericardium: a case report.
A large pericardial effusion was discovered in an asymptomatic 12-year-old boy admitted for an elective orthopedic procedure. On physical examination, heart rate was 96 and blood pressure was 130/70 without paradox. The neck veins were not distended, but heart tones were distant. Chest roentgenogram (CXR) showed an enlarged cardiac silhouette. Echocardiogram showed a massive pericardial effusion compressing the right atrium, with depressed ventricular contractility. Pericardiocentesis yielded 450 mL of chylous fluid. A percutaneous pericardial drain was placed and drained another 400 mL of chyle. Pericardial fluid reaccumulated even though the patient was on a low-fat diet, and 1 week after admission left thoracotomy was performed with partial pericardiectomy and pericardial window. There was 1 L of chyle in the pericardial sac; frozen section of the pericardium showed lymphangiectasia. Chest tube drainage diminished rapidly and the patient was discharged. Follow-up CXR at 1 week showed fluid in both pleural spaces requiring bilateral tube thoracostomies again draining chyle. Even with total parenteral nutrition (TPN), 500 mL/d of chyle drained from the pleural tubes. Right thoracotomy with ligation of the thoracic duct was performed after 1 week of TPN. Pleural drainage abruptly dropped, and there has been no reaccumulation in either the pleural spaces or pericardium at 6-month follow-up. This case dramatically supports early thoracic duct ligation and partial pericardiectomy as the treatment of choice for primary massive chylopericardium.
Division Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Chicago, IL 60614.
C A
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Musemeche
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Riveron
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Backer
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Zales
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Idriss
D002648:Child; D002916:Chylothorax / Q000150:complications / Q000175:diagnosis / Q000178:diet therapy / Q000601:surgery; D004452:Echocardiography; D006801:Humans; D008297:Male; D010490:Pericardial Effusion / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D010491:Pericardial Window Techniques; D010492:Pericardiectomy; D010996:Pleural Effusion / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D013897:Thoracic Duct / Q000601:surgery*