Chylothorax After Childbirth

rt'\'Pal ..d a pH of 7.51, PaCO, of 3.'5 mm Hg, PaO, of 61 mm Hg, and 90 p..rcent saturation. A chest x-ray film (Fig I) demonstrated a V-PI. shunt cath..ter in thP lt•ft pleural spaee, with hoth free and lt><:ulated fluid. Pleural fluid revealed pumlent material with a white hlood <'<'II munt of 110.000/en mm . with 7R percent PMNs, glucose level of7 rng/dl , pH < 7.0, LDH level of7,600 units/L, and Grampositive eocd in pairs and <:ram-positive rods seen on Gram stain. Tuhe thoramstorny was performed , with removal of I,ROO ml of pumlent material; and antimiernhial therapy with ceftriaxone and vaneomydn was hegun. No eviden<·e of underlying pulmonary parenehymal infiltrates was noted. Culture of plt>ural fluid revealed Staphylot·occus PJ>idennidis and Streptococcti-V mitis. Thirty-six hours aftt>r the institution of antihiotk therap}: the patient was hrought to the operating morn for exteriori7.ation of the proximal end and rt•moval of tht• distal end of the V-PL shunt. A sample of turhid CSF with a white hlood eell <.1>tlllt of 480/cn mm was ohtained at that tirnf'. Culturps ofCSF. hl()(>t' wt>eks of et>ftriaxone therapy. A small amount of l()(·nlated pleural Huid persisted until discharge. DtscusstoN The present report describes the development of empyema due to Staph epidennidis and Strep mitis ipsilateral to a V-PL shunt, prest>nting with altered mental status, fever, and leukocytosis. Pleocytosis ofCSF was observed, although cultures were negative, presumably because this specimen was obtained after administration of antimicrobials. The absence of roentgenographically demonstrable pulmonary parenchymal infiltrates suggests that the pleural infection was not spcondary to pneumonitis. Furthermort', the organisms prespnt on culturt> are among those frequently reported to cause V-PL shunt infections" and are not often a primary canst' of pnt>umonia. These factors suggest that the shunt catheter was tht> most likely source of pleural infection. Vt>ntriculopleural shunts are conduits from the ventricles to tht> plt>ural space. In particular, transfer of glioblastoma ct>lls to the plt•ural space via a V-PL shunt has been reported in two patients. 1. 7 It would thert>fore seem reasonable that infection originating proximally in a V-PL shunt could also he transferred to the pleural space, producing empyema by direct delivery of organisms via the shunt catheter. To our knowledgt•, infection of pleural effusions resulting from V-PL shunts causing frank empyema has not been previously reportt•d . As shunt infection is a known complication of this procedure , ' a high index of suspicion must be maintained for infection in both tht> CSF and any associated pleural effusion whf'n thesf' patients present with fevers without another obvious source. Early sampling of the CSF and pleural fluid will diret·t prompt institution of antimicrobial therapy and shunt extt>rinri;r.ation, which may prevent the development of frank t>mpyema . REFERENCES

2 3 4 .'5

RansohoffJ. Ventriculopleural anastomosis in treatment of midline ohstrncft>d masses. J Neurosurg 19.'54;11 :295-301 Vt>nes JL. Pleural effusion and eosinophilia following ventriculopleural shunting. Dev Med Child Neurol 1976; 16:72-6 Venes JL. Shaw RK. Ventriculopleural shunting in the managemt>nt of hydrocephalus. Childs Brain 1979: 4:45-.'50 Hoffman JH, Hennick EB. Humphreys RP: Experience with ventrienlopleural shunts. Childs Brain 19&'3; 10:404-13 Nixon Hll. Vt>ntricnlo-plenral drainage with a valve. Dev Med

Child Neur 1962; 4:301-02 6 Venes JL. Control of shunt infection: report of 1.'50 <.1msecntive cases. J Neurosurg 1976; 45:311-14 7 Wakamatsu T, Matsuo T, Kawano S, Teramoto S, Matsumura H. Glioblastoma with extracranial metastasis through ventriculopleural shunt: case report . J Neurosurg 1971; 34:697-701

Chylothorax After Childbirth* Sue IGllion Cammarata , M.D.;t

Robert E. Brush, Jr., M.D., F.C.C .P.;* and Robert C. Hyzy, M.D.§

We report a case of chylothorax which appeared in a mother after childbirth. Disruption of the thoracic duct occurred with the high intrathoracic pressures generated by the Valsalva maneuver used by the patient during labor to "push." No evidence of other trauma or malignancy were fOund and the patient did well after use of total parenteral nutrition, thoracotomy with thoracic duct ligation, and (Che11t 1991; 99:1539-40) pleurodesis.

T

raumatic events precipitating chylothorax are usually obvious, but minor trauma has been noted to result in chylothorax. We recently treated a mother who presented with chylothorax after prolonged labor, ultimately requiring thoracotomy for ligation of the thoracic duct. CASE REPORT

The patient was a 20-yeaN>Id nulliparous white woman who went into labor at the end of an uneventful pregnancy. More than three hours were spent in the second stage with the fetal head remaining at I + station despite repeated pushing by the mother. Variable deceleration of the fetal heart rate and meconium staining of amniotic fluid were noted, necessitating a low transverse ceasarean section without complications. Achest roentgenogram after delivery documented a right pleural effusion (Fig 1) hut no other diagnostic work-up was pursued. The patient was discharged home without further complications. Three weeks after the ceasarean section, the patient noted a dry cough and dyspnea. Chest roentgenogram demonstrated opacification of the right hemithorax. Thoracentesis yielded 3 L of milky fluid, which was found to be chylous with a protein level of 3.8 g/dl, triglycerides, 2,730 mwdl, and large chylomicron hand of 40 percent on lipoprotein electrophoresis. The fluid white hlood cell munt was 6,015/cu mm with 97 percent monocytes and 3 percent neutrophils. Pleural fluid glucose value was 98 mg/dl with an LDH level of 197 lUlL. Her dyspnea resolved, but three days later, she was admitted for recurrent effusion. Except for her ceasarean section, the patient had no significant past medical history, no history of trauma, and no constitutional complaints. Physical examination revealed a healthy appearing female at 60.0 kg (132 lhs). There was no lymphadenopathy on examination and lung findings were consistent with a right pleural effusion. Admitting laboratory data included a nonnal white blood cell count, semm total protein value of 6.4 gldl; albumin, 3.4 g/dl; and cholesterol , 184 mg/dl. A PPD was not reactive and culh1res of pleural fluid were negative for Mycobacteria and bacteria. *From the Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, and Michigan State University Kalamazoo Center For Medical Studies, Kalamaz()(l. tFellow. *Associate Clinical Professor. §Senior Staff Physician . CHEST I 99 I 6 I JUNE. 1991

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l'u :nw I. AI' du·st ro•• ntgenogram takt·n tlm•t• days postpartum d patient l"ntinued to do well and dwst r<><•ntgenogram at ont• and two yt·ars of f<>llow-up showt>d a m<>st dt>cn'ffusions. DISCUSSION

The causes of chylothorax are typically gnmpt•d into four dasses-tmnor. trauma. idiopathic. and miscellaneous.' Tumor aeeounts fi>r over 50 percent of all east•s of chylothorax. Therefi>re. in t•valuating non traumatic or idiopathic chylothorax . tlw possibility of lymphoma or otlwr neoplasm must lw adequately investigated . Trauma is the se<.~md major caust• of chylothorax . Usually due to signifieant blunt injury or penetrating wounds. minor trauma . such as stretching, ' straining,' <.~mgh. ' · '·' and hypert•xtf'nsion injuries,"·'" have also het·n given as etiologies for chylothorax. Chylothorax n•s1rlting from childhirth has heen reported on only one other occasion . '' In that patit•nt. chylothorax was finmd after prolongt•d vaginal delivery wlwre t•xll'nsive t•xlt'rnal pressun· was applied to the abdomen. During labor in our patient. no exte rnal abdominal pn•ssure was applied. hut a prolonged period was spent at tlw seeond stage with the motlwr pushing throughout this time. Slw had a pleural eflirsion aftt•r delivt•ry : lwwt•ver. its largt• sizt•, progression, and ehylous uatun· iudieated that it was not a typical 1540

postpartum pleural effusiou, since postpartum pleural effusions. although common. an• small and resolvt• spontanemrsl~: " The low transverse eeasan•
Light R\Y. Pleural diseases. Philadelphia: Lea and Fd>iger, 1983: 209-19

2 MacFarlane JR, Holman CW Chylothorax. Am Rev Respir Dis 1972; 105:2R7-91

3 Reilly KM ,Tsou E. Bilateral chylothorax: a case report following episcKies of stretching. JAMA 1975; 233;536-37 4 Ht>r.log KA . Bransmm JJ. Spontaneous chylothor.lX. Chest 1974; 65:346-47 5 Lampson RS . Traumatic chylothnrax . J Thnr Surg 194R; 17: 77R-91

6 Kjddsen CS , StrnVt>-Christensen E. Chylothorax: a~·ase report. Scand J Thor Cardiovasc Surg 1974: R:l38-41 7 Sundherg RH . ChylothonlX: a case report . Calif Med 1948;68: 99

8 Longmore AJ. ChylothonlX. Canad M A J 1952; 66:377-79 9 Mt>ade Rll . Spontaneous chylothonLx. Arch Intern Med 1952; 90:30-.'36

10 Shackdford RT, Fislwr AM. Traumatic chylothonlX . South Med

J 1938: .'31:766-74 II lhrnling C. Axclsson G. Peterffy A. Chylothontx as a

~"mph­

cation aflt•r deliVt'ry. Ada Oh <:yn Scand 19R7: 66:381-R2 12 Hughson \VC . Frit>dman PJ. t>t al. Postpartum pleural effusion:

a <.•nnmon radiologil' finding. Ann Intern Med 19R2: 97:R56-58 13 Sharpt·y-Sehaft•r EP. Efft'l•ts ofValsalva"s mant'IIVt'r ontht> normal

and failing circulation . Br Mt>d J 195.'); I :693-99 14 Sdunidt A. Chylothorax . Ada Chir Scand 1959; 111>:5-12 Chylothorax after Childbirth (Cammarata. Brosh, Hyzy)