Singapore Med J 2011; 52(9) : e187 Case Report Constrictive pericarditis presenting as chylothorax Naeem M, Sobani Z A, Zubairi A, Fatmi S, Khan J A ABSTRACT Chylothorax is a rare clinical condition that can be attributed to a damaged thoracic duct. The condition is suggested by aspiration of milky white fluid from the pleural cavity and is commonly associated with either malignant diseases or trauma (e.g. cardiothoracic surgery). We present the case of a 15-year-old boy with chylothorax, whose effusion was due to constrictive pericarditis. The definitive treatment of chylothorax involves identification and management of the underlying pathology. We suggest that when dealing with cases of chylothorax, constrictive pericarditis should be considered among the causes. Keywords: chylothorax, constrictive pericarditis, tuberculous pericarditis Singapore Med J 2011; 52(9): e187–e189 INTRODUCTION Chylothorax is a rare clinical condition attributed to a damaged thoracic duct. The damage is most commonly associated with either malignant disease or trauma (e.g. cardiothoracic surgery). (1) Other reported causes include thrombosis of the superior vena cava or subclavian veins, pulmonary lymphangiomyomatosis, ilariasis, Kaposi’s sarcoma in acquired immunodeiciency syndrome (AIDS), heart failure, amyloidosis, sarcoidosis, Behcet’s syndrome, tuberculosis (TB) and constrictive pericarditis. (1-4) Clinical features of chylothorax depend on the rate of development of effusion. Rapid effusions are associated with hypovolaemia and breathing dificulty, whereas effusion of large volumes may be associated with immunosuppression due to the loss of immunoglobulins and lymphocytes in the chyle. (5,6) We present the case of a 15-year-old boy with treated pleural and pericardial TB leading to constrictive pericarditis and chylothorax. CASE REPORT A 15-year-old boy with no known comorbidities presented to our outpatient pulmonology clinic with complaints of dyspnoea on exertion and persistent dry cough for the past three months. He had experienced similar symptoms associated with fever and weight loss three years ago. Radiological imaging revealed moderate left-sided pleural effusion and ascites, which were therapeutically drained. Analysis of the pleural luid revealed protein content > 4.5 g/dL and a white blood cell count of 1,200 cells/ml, with 90% lymphocytes. Echocardiogram showed the presence of signiicant pericardial effusion. The patient was diagnosed with pleural/pericardial TB and started on a four-drug antituberculous treatment regimen for nine months at another centre. His symptoms as well as clinical and radiological indings resolved upon completion of the medical therapy. A year following the cessation of therapy, his pleural effusion returned, and the luid was drained multiple times at various medical centres in another city. There was no fever, weight loss, sputum, haemoptysis, joint pain or pedal oedema associated with his condition, and there was no history of tobacco or drug use. The patient then presented to our department for an opinion regarding the cause of his recurrent pleural effusion. On examination, he was a lean and of average height. His blood pressure was 110/70 mmHg, pulse Respiratory Medicine, Kettering General Hospital, Rothwell Road, Kettering, Northamptonshire NN16 8UZ UK Naeem M, MBBS Registrar Medical College, Aga Khan University, Stadium Road, Karachi 74800, Pakistan Sobani ZA Medical Student Section of Pulmonary and Critical Care Medicine Zubairi A, DABIM Associate Professor Khan JA, FRCP Professor and Head Section of Cardiothoracic Surgery, Department of Surgery Fatmi S, DABCTS Associate Professor Correspondence to: Dr Javaid A Khan Tel: (92) 213 4864688 Fax: (92) 21 3493 4294 Email: javaid.khan@ aku.edu Fig. 1 Anteroposterior chest radiograph on presentation shows moderate left-sided pleural effusion, with loss of costophrenic angle and heart shadow.