Chylous ascites and chylothorax: a case study

A 40-year-old male patient was admitted with the symptoms of progressive dyspnea, orthopnea, and abdominal distension of 2 months duration. On examination, vitals were as follows: BP 100/80 mmHg, pulse rate 120/min, and respiratory rate 36/min. He had small bilaterally supraclavicular nodes, a large right axillary lymph node, and the jugular venous pressure was elevated. On auscultation, breath sounds were decreased over both lung bases and heart sounds were only faintly audible. The clinical signs suggestive of free fluid were present in the abdomen. Laboratory findings revealed elevated serum creatinine (2.0 mg/dl) with normal hematocrit, liver function test (LFT), and electrolyte. Chest X-ray posteroanterior (PA) view showed bilateral pleural effusion and pericardial effusion. Thoracocentesis yielded a milky fluid with the following biochemical composition: total protein 3.6 g/dl, albumin 2.0 g/dl, glucose 118 mg/dl, and LDH 121 U/l. Cell count of the fluid showed 1,300/mm of WBCs; of which 96% were lymphocytes and 4% polymorphs, triglycerides 411 mg/dl, cholesterol 70 mg/dl, and chylomicron 260 mg/dl. Pleural fluid cytology showed atypical cells and closed pleural biopsy revealed non-specific chronic inflammation. Cultures of the fluid including mycobacterial culture, of peritoneal and pleural fluid were non-contributory. Two dimensional (2D) ECHOcardiograph showed moderate pericardial effusion with collapse of right atrium and right ventricle, suggesting cardiac tamponade. Pericardiocentesis was done immediately which revealed hemorrhagic fluid. Pericardial fluid cytology showed atypical cells suggestive of malignancy, although biochemical analysis confirmed that it was not chylous. The fine needle aspiration cytology (FNAC) of the axillary lymph node revealed signet ring cell adenocarcinoma (Fig. 1). Computed tomography (CT) of the thorax was done after thoracocentesis to find out the possible etiology. It showed bilateral pleural effusion, pericardial effusion, paratracheal, and mediastinal lymph nodes up to 8 mm with a calcified granuloma in the left upper lobe (Fig. 2). FNAC of these lymph nodes were not done in view of smaller size of lymphnode. Abdominal ultrasonography and CT of the abdomen showed left sided hydorneprhosis with moderate ascites. No lymphadenopathy or tumors were detected during abdominal CT. Other investigations to locate primary such as fiberoptic bronchoscopy, upper GI endoscopy, and colonoscopy could not be done due to unfavorable physical condition. The final diagnosis was metastatic signet ring cell adenocarcinoma of unknown primary with chylothorax, chylous ascites, and probably malignant pericardial effusion. During hospital stay, patient required repeated thoracocentesis and pericardiocentesis. He was started on low cholesterol diet with medium chain triglyceride supplements. To minimize nutritional depletion, intercostal tube was not inserted. In view of poor prognosis the patient and his family opted for treatment at their hometown. He was thus sent home with recommendations to commence treatment with a local palliative care unit.