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NEONATAL PLEURAL EFFUSION DIFFERENTIAL DIAGNOSIS

– Chyle (most common cause of neonatal effusion)
– Non-Immune Hydrops
– CHF / Congenital Heart
– PPHN
– Immune Hydrops
– RF Infectious
– GBS
– Meconium Aspiration
– Myotonic Dystrophy
– Birth Trauma - thoracic duct injury

FURTHER HISTORY

From the chest tube, the pleural effusion was described as a milky opalescent fluid (described as chyle). The cell count revealed 129,000 white blood cells (99% lymphocytes). Glucose was 6.3 (units?)(same as plasma) and the LDH was 118(units?) (no serum level found). Pleural protein was 33 g/L (serum total protein 50g/L). Triglycerides were sent but results were unavailable.

As a result of the chylothorax, JB had chest tubes placed bilaterally for continuous re-accumulation of chyle. The chest tubes were eventually discontinued after 2 1/2 weeks.

Nutritionally, our patient was managed on total parenteral nutrition (TPN) for 19 days and was eventually switched to Portagen w/ medium chain triglycerides (MCT) & Caloreen (30cal/oz). On this nutritional regime, JB started to gain weight. From a respiratory perspective, JB was ventilated for 14 days and was on CPAP for 4 days.

OUTCOMES OF CONSERVATIVE MANAGEMENT OF CHYLOTHORAX (2,3)
With Conservative management (drainage plus either MCT diet or TPN), 89% of patients have eventual resolution of their chylothorax. Within the congenital chylothorax population, 70% of these patients resolve within 3 weeks of treatment. If the chylothorax does not resolve after 3+ weeks of conservative management, surgical management needs to be considered. This includes either: open thoracotomy & ligation of affected thoracic duct, pleurodesis, or pleuroperitoneal shunt if at an experienced center.

COMPLICATIONS OF PROLONGED CHYLOTHORAX (3)
The effects of a prolonged chylothorax can be divided into local and systemic effects. Local effects include impaired cardiac and respiratory function. Systemic Effects are caused by the loss of chyle, lymphocytes and protein within the pleural fluid.

Problems include: Impaired immune function (loss of T-lymphocytes), nutritional depletion, metabolic instability, electrolyte imbalances and hypercoagulability.

FURTHER HISTORY

Our patient did suffer multiple complications. It is unclear of the cause or etiology underlying these complications though it is presumed that some of them stem from the chronic chylothorax.

The complications included: sepsis with klebsiella, acute renal failure, thrombocytopenia, aortic thrombus secondary to the umbilical artery catheter, hyperbilirubinemia, and asymptomatic cholelithiasis.

Upon discharge, at 6 months age, JB was placed on Portagen with MCT's and Caloreen - 30cal/oz with eventual weight gain.

JB was readmitted to the pediatric intensive care unit on December 21/98 with RSV positive respiratory distress.

This is our patients admission CHEST X-RAY in the PICU.


ENLARGE the X-ray ABOVE.

WHAT DOES IT SHOW?


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