Case Presentation 2011.04.14 R3 謝旻玲 / VS 王玠能

Identifying Information Name: 黃○明 Gender: boy Age: 10 Chart No.: 142870○○ Admission Date: 2011/3/22 Chief Complaint: Progressive shortness of breath for 3 weeks

Present Illness Productive cough for 3 weeks Progressive shortness of breath Chest pain for 2 days No fever Hit while ridding bicycle 3 weeks ago No underlying disease

Physical Examination Chest: Heart: Abdomen: Extremities: decreased breathing sound over right lung percussion: dullness over R’t chest No crackles, no wheezing no subcostal retraction Heart: regular heart beat, no murmur Abdomen: Hypoactive bowel sound soft, not distended L/S: impalpable / impalpable Tenderness (+) over right abdomen No rebound tenderness Extremities: freely movable no pitting edema Skin: fine, no rash Consciousness: clear Appearance: ill-looking Vital sign: T/P/R: 36.8 / 124 / 34 BP: 119/83　mmHg Activity: fair Head: conjunctiva: not anemic sclera: not icteric throat: mild injected tonsil: not enlarged eardrum: intact, cerumen impaction over right eardrum Neck: supple, LAP(-)

Lab Data

Lab Data Blood Gas PH: 7.376 PCO2: 33.3 mmHg BE: -5.1 mmol/l HCO3: 19.1 mmol/l SO2: 96.2 %

Chest CT CT of chest starts scanning from lung apex to adrenal glands with and without IV contrast injection and shows: l. The trachea and bilateral main bronchi are normally identified without endobronchial lesion. 2. The mediastinum and hilar regions are free from lymphadenopathy. 3. In lung window setting, the visible lung parenchyma is clear and the bronchovascularity appears normal. 4. The pleura and diaphragm appear unremarkable. 5. The visible liver and adrenal glands are negative. 6. Missive right side pleural effusion with right hemilung collapse and meidastinum shifting to left. IMP: Missive right side pleural effusion with right hemilung collapse and meidastinum shifting to left.

Differential Diagnosis?

After Drainage…

Diagnosis Chylothorax, right Respiratory distress due to massive chylothorax

Chest MRI Chest MRI without gadolinium injection focuing on paraspinal are is performed and shows the following findings: 1. Moderate amount of right plerural effusion. 2. Clustered fluid collection at above cisterna chyli with associated collapsed proximal thoracic duct. 3. Some acinar opaciites at RUL and RML. 4. Focal edema and infiltrates at bilateral costovertebral junction at the level of T10-11 and T11-12. 5. Right pigtail inserted in place. 6. Right chest wall subcutaneous edema and fluid collection. Imp: 1. Clustered fluid collection at above cisterna chyli with associated collapsed proximal thoracic duct. Suspicious for leakage side. 2. Focal edema and infiltrates at bilateral costovertebral junction at the level of T10-11 and T11-12. The nature? 3. Moderate amount of right plerural effusion with pigtail tube inserted in place.

Chest CT

MCT Diet 695 (ml) 1521 77 446 90 174 76 34 22 874 314 6 2 1114

Octreotide OP MCT Diet 100 772 700 16 34 4 1130

Chylothorax

Anatomy of Thoracic Duct

Diagnosis of Chylothorax Paediatric Respiratory Reviews 10 (2009) 199–207

Treatment Non-operative management Surgical management Thoracentesis Continuous drainage Dietary modifications Somatostatin and analogues (octreotide) Surgical management Ligation of thoracic duct or mass ligation Pleurodesis Pleuroperitoneal shunt