Indexing Title: RDELEON’s Medical Anecdotal Report [04-4]

MAR Title:  A first for all of us

Date of Medical Observation: May 2004

Narration:

JV a 3mos/M was admitted at the Pediatrics ward and was diagnosed to have Pleural Effusion probably secondary to Pneumonia. A thoracentesis was done by pediatrics resident and after the said procedure, x-ray revealed pneumothorax. The patient was referred to our department for Chest Tube Thoracostomy (CTT) insertion.

CTT was inserted by one of our surgery residents. After 2 days, CTT output was noted to be milky white which was consistent with the milk that was being given to him. Further work-up showed that the patient had Chylothorax.

The patient was referred to both Pediatric Surgery and Thoracocardiovascular Surgery (TCVS) service.

CT    CT scan was requested by our TCVS service consultant to confirm a mass on the mediastinum, which is the most common cause for cisterna chyle to rupture.  True enough, the CT scan revealed a mass which causes the chylothorax.

Removal of the mass was advised to the parents. Since the said procedure contemplated was difficult and operating room facilities were inadequate in our institution, our service consultant advised transfer of the patient to PGH.

 The patient was coordinated with the TCVS service at the PGH and they were willing to accept the patient, but unfortunately, the patient would be first admitted by the pediatrics department. Efforts were made to coordinate the transfer of the patient to PGH.

Due to lack of available beds, patient was not admitted. Everyday the patient was referred for possible transfer.

The patient was still being managed by the service while awaiting transfer. We noted that there was minimal to no output in the CTT. Further evaluation showed resolution of the chylothorax.  This finding was affirmed by the service consultant who had never encountered a spontaneous resolution of chylothorax before.

Insights (Discovery, Stimulus, REINFORCEMENT):

Chylothorax secondary to a mass usually requires removal of the mass for complete resolution. This view is shared and attested by our service consultant. Through this experience we discovered that certain cases of chylothorax resolve spontaneously.

We also learned that not all disease entities will follow its usual course. For these cases, we should keep an open mind in managing and treating our patients. We should also be ready in dealing with unexpected cases.