Abstract Introduction Chylothorax is a rarely described complication in patients with advanced human immunodeficiency virus (HIV) complicated by Kaposi sarcoma (KS). The mechanism of chylothorax formation is thought to be disruption of the thoracic duct by KS lesions. Here, we present a case of bilateral chylothorax in a patient with KS refractory to medical management requiring procedural intervention. Case Presentation A 39-year-old man with advanced HIV complicated by KS presented with cough, fever, chills, and acute hypoxemic respiratory failure. Prior to this admission, his CD4 count was 34 cells/uL, and both skin and colon biopsies were positive for Kaposi sarcoma. On presentation, chest computed tomography demonstrated bilateral pleural effusions (Figure 1.1). Thoracentesis was performed bilaterally and yielded exudative, lymphocytic chylous pleural fluid (Figure 1.2) with undetectable cholesterol levels and triglycerides of 198 mg/dL, diagnostic of bilateral chylothorax. Bilateral chest tubes were placed, each of which initially drained over 1 L of fluid. The patient was started on an ultra-low-fat diet, medium-chain triglyceride (MCT) supplementation, and 50 mcg octreotide three times per day. For the next 13 days, the cumulative daily chest tube output remained in excess of 300 mL. A lymphangiogram with cisterna chyli maceration was performed (Figure 1.3). Following the procedure, chest tube output gradually decreased, and the chest tubes were removed without recurrence of the effusions. The patient’s diet was liberalized. One week after chest tube removal, the pleural effusions had not recurred. Pleural fluid cytology was negative for malignant cells. Discussion Non-traumatic chylothorax typically occurs due to obstruction of the thoracic duct, with common causes including lymphoma, metastatic cancer, and sarcoidosis. In advanced HIV, Castleman’s disease and KS can also cause obstruction and lead to chylothorax. Bronchoscopy or pleural biopsy demonstrating KS legions in the airways or pleura support the diagnosis of KS-associated chylothorax. However, as direct visualization of the legions does not change clinical management, the diagnosis is primarily clinical. Chylothorax refractory to conservative measures may be complicated by respiratory compromise, electrolyte derangements, worsening immunosuppression, and malnutrition. Advanced options for management of recalcitrant chylothorax include magnetic resonance lymphangiography which can be therapeutic in up to 62% of cases due to closure of the thoracic duct leaks by the contrast agent. Additional strategies include thoracic duct ligation, and in rare cases, pleurodesis. Treatment of KS-associated chylothorax with paclitaxel or doxorubicin have additionally been described. Clinicians should consider early procedural intervention for patients with chylothorax secondary to KS. This abstract is funded by: None
Jamali et al. (Fri,) studied this question.