Asian Cardiovasc Thorac Ann 1998;6:235-236
© 1998 Asia Publishing EXchange Pte Ltd
Primary Chylopericardium in a Heroin Addict
Massimo Chello, MD,
Pasquale Mastroroberto, MD,
Francesco Cirillo, MD,
Emanuele Malta, , MD
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Department of Cardiac Surgery Medical School of Catanzaro Catanzaro, Italy
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For reprint information contact: Massimo Chello, MD Via S Giacomo dei Capri 29 Napoli 80128, Italy Tel: 39 961 71 2307 Fax: 39 961 77 5373 Email: chello{at}unicz.it
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ABSTRACT
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We describe a case of primary chylopericardium following acute Staphylococcus aureus endocarditis in a 33-year-old female heroin addict. The patient underwent surgical ligation of the thoracic duct after a low-fat diet failed to control the fluid accumulation. Three months postoperatively, the patient was in a good general condition and no pericardial effusion was observed.
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INTRODUCTION
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Primary chylopericardium is a rare clinical occurrence in which chylous fluid accumulates in the pericardial cavity. The specific diagnosis of chylopericardium is made by pericardiocentesis and analysis of the fluid. We present here a case of chylopericardium following infective endocarditis in a heroin addict.
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CASE REPORT
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A 33-year-old female with a history of heroin addiction was admitted to our hospital in 1997 with high fever in spite of antibiotic therapy, weight loss, and tender nodules on the pulpae of three fingers of her left hand. Auscultation revealed a grade III pansystolic murmur at the left sternal edge that intensified during deep inspiration. A precordial echocardiogram showed moderate tricuspid regurgitation with thickened valvular leaflets and no vegetations. Staphylococcus aureus grew in cultures of blood taken on admission. Infective endocarditis was diagnosed and the patient was treated with intravenous vancomycin.
After 2 weeks of antibiotic therapy, her clinical status improved although she remained afebrile. Antibiotic therapy was continued for 2 more weeks and she was discharged in good condition. An echocardiogram obtained before discharge showed only mild tricuspid regurgitation. One month later, the patient was readmitted to our hospital complaining of shortness of breath, chest pain, and edema of the lower limbs. She was afebrile. Chest radiograph revealed significant cardiomegaly and a large amount of pericardial effusion was detected by echocardiography. A thoracentesis was performed and 900 mL of a milky-colored fluid was drained. A chest tube was left in place. The diagnosis of primary chylopericardium was established by analysis of the aspirate, which showed a high triglyceride and protein content, a predominance of lymphocytes, and the presence of fat globules by sudan III staining. Blood studies were negative for bacterial growth. Transesophageal echocardiography showed moderate tricuspid valve reflux and good left and right ventricular function. The patient was placed on a low-fat diet and an exercise program. Radiologic diagnosis by computed tomography combined with lymphangiography failed to demonstrate any communication between the thoracic duct and the pericardium. In spite of dietary management, continuous drainage of chylous fluid (1000 mL) occurred during the following 10 days. The patient was therefore scheduled for surgery. Two hours preoperatively, 250 mL of whole milk was infused into the stomach through a nasogastric tube. Through a left thoracotomy, the descending aorta was dissected and double taped and after careful dissection behind the aorta, the thoracic duct was ligated and resected. A pericardial window was constructed and a chest tube was positioned. The postoperative course was uneventful and the patient was discharged one week later. Three months post-operatively, the patient was asymptomatic and trans-thoracic echocardiography showed only moderate tricuspid insufficiency.
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DISCUSSION
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Infective endocarditis is one of the most serious complications of intravenous drug abuse and it is responsible for 14% of all deaths in drug addicts.1 The involvement of the tricuspid valve is a frequent finding. Staphylococcus aureus is the most common organism found in addicts and the response to medical treatment is usually good but surgery is indicated when the condition is complicated by repeated pulmonary emboli or if the size of the vegetation increases or remains at more than 1 cm in diameter on echocardiography.2 Primary chylopericardium is a rare disorder in which chylous fluid accumulates in the pericardial cavity. To our knowledge, 90 cases including our present case have been reported since the first report by Groves and Effler3 but this is the first report of this condition in a heroin addict with a recent history of infective endocarditis.
Although the clinical findings in our patient have been extensively evaluated, a correlation between the chylopericardium and the recent episode of infective endocarditis has not been elucidated. An anomalous communication between the thoracic and the pericardial lymphatics resulting in chylous reflux has been advocated as a possible cause.4 However, in our case, we failed to demonstrate any chylous leakage into the pericardium by computed tomography combined with lymphangiography. As pointed out in the review by Akamatsu and colleagues5, another possible explanation could be the presence of damaged valves combined with abnormally elevated pressure in the thoracic duct.
Chan and colleagues6 and Akamatsu and colleagues5 have addressed some interesting points regarding the treatment of isolated primary chylopericardium. In our case, because the patient was unresponsive to conservative treatment, surgical therapy was the only option in order to avoid later progression of cardiac tamponade or constrictive pericarditis. Ligation and resection of the thoracic duct and a wide pericardial window through a left thoracotomy were considered to provide the best solution in this case.
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REFERENCES
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Mathew J, Addai T, Anand A, Monobel A, Maheshwari P, Freels S. Clinical features, site of involvement, bacteriological findings, and outcome of infective endocarditisin intravenous drug users. Arch Inter Med
1995;155:1641–8.[Abstract/Free Full Text]
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Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic features in 102 patients. Ann Intern Med
1992;117:560–6.
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Groves LK, Effler DB. Primary chylopericardium. N Engl J Med
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Yanokopoulos NA, Akbarian M, Sturkey GW, Abelmann WH. Isolated chylopericardium: diagnosis, hemodynamic studies and surgical treatment. Am J Cardiol
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Akamatsu H, Amano J, Sakamoto T, Suzuki A. Primary chylopericardium. Ann Thorac Surg
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Chan BBK, Murphy MC, Rodgers BM. Management of chylopericardium. J Pediatr Surg
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ABSTRACT
INTRODUCTION
