1. Case Presentation
R3 謝旻玲 / VS 王玠能

2. Identifying Information
Name: 黃○明
Gender: boy
Age: 10
Chart No.: ○○
Admission Date: 2011/3/22
Chief Complaint:
Progressive shortness of breath for 3 weeks

3. Present Illness Productive cough for 3 weeks
Progressive shortness of breath
Chest pain for 2 days
No fever
Hit while ridding bicycle 3 weeks ago
No underlying disease

4. Physical Examination Chest: Heart: Abdomen: Extremities:
decreased breathing sound over right lung
percussion: dullness over R’t chest
No crackles, no wheezing
no subcostal retraction
Heart:
regular heart beat, no murmur
Abdomen:
Hypoactive bowel sound
soft, not distended
L/S: impalpable / impalpable
Tenderness (+) over right abdomen
No rebound tenderness
Extremities:
freely movable
no pitting edema
Skin: fine, no rash
Consciousness: clear
Appearance: ill-looking
Vital sign:
T/P/R: 36.8 / 124 / 34
BP: 119/83　mmHg
Activity: fair
Head:
conjunctiva: not anemic
sclera: not icteric
throat: mild injected
tonsil: not enlarged
eardrum: intact, cerumen impaction over right eardrum
Neck: supple, LAP(-)

6. Lab Data

7. Lab Data Blood Gas PH: 7.376 PCO2: 33.3 mmHg BE: -5.1 mmol/l
HCO3: 19.1 mmol/l
SO2: 96.2 %

8. Chest CT
CT of chest starts scanning from lung apex to adrenal glands with and without IV contrast injection and shows:
l. The trachea and bilateral main bronchi are normally identified without endobronchial lesion.
2. The mediastinum and hilar regions are free from lymphadenopathy.
3. In lung window setting, the visible lung parenchyma is clear and the bronchovascularity appears normal.
4. The pleura and diaphragm appear unremarkable.
5. The visible liver and adrenal glands are negative.
6. Missive right side pleural effusion with right hemilung collapse and meidastinum shifting to left.
IMP:
Missive right side pleural effusion with right hemilung collapse and meidastinum shifting to left.

9. Differential Diagnosis?

10. After Drainage…

12. Diagnosis Chylothorax, right
Respiratory distress due to massive chylothorax

13. Chest MRI
Chest MRI without gadolinium injection focuing on paraspinal are is performed and shows the following findings:
1. Moderate amount of right plerural effusion.
2. Clustered fluid collection at above cisterna chyli with associated collapsed proximal thoracic duct.
3. Some acinar opaciites at RUL and RML.
4. Focal edema and infiltrates at bilateral costovertebral junction at the level of T10-11 and T11-12.
5. Right pigtail inserted in place.
6. Right chest wall subcutaneous edema and fluid collection.
Imp:
1. Clustered fluid collection at above cisterna chyli with associated collapsed proximal thoracic duct. Suspicious for leakage side.
2. Focal edema and infiltrates at bilateral costovertebral junction at the level of T10-11 and T The nature?
3. Moderate amount of right plerural effusion with pigtail tube inserted in place.

14. Chest CT

15. MCT Diet
695
(ml)
1521 77
446 90
174 76 34 22
874
314 6 2
1114

16. Octreotide OP
MCT Diet
100
772
700 16 34 4
1130

17. Chylothorax

18. Anatomy of Thoracic Duct

19. Diagnosis of Chylothorax
Paediatric Respiratory Reviews 10 (2009) 199–207

21. Treatment Non-operative management Surgical management Thoracentesis
Continuous drainage
Dietary modifications
Somatostatin and analogues (octreotide)
Surgical management
Ligation of thoracic duct or mass ligation
Pleurodesis
Pleuroperitoneal shunt