Pleural Effusion-Pseudochylothorax

(aka Cholesterol Pleurisy, Chyliform Effusion, Cholesterol Effusion)

Epidemiology

  • xxxx

Etiology

  • [[Rheumatoid Arthritis]]
  • [[Tuberculosis]]
  • Post-Therapeutic Pneumothorax
  • Trauma with Hemothorax

Physiology

  • Long-standing pleural fluid (usually >5 years), which is typically encapsulated in a area of thickened pleura -> concentration of cholesterol in the fluid
  • Slow enlargement over time

Diagnosis

  • CXR/Chest: necessary to define the anatomy
    • Markedly thickened pleura (due to irritation of pleura)
  • Pleural Fluid: usually thick, opalescent, whitish or coffee-colored (due to high fat content)
    • Important Aspects of Thoracentesis:
      • The pleural peel is often thick (and may be calcified) -> may make puncture difficult
      • The walls around the fluid are stiff -> negative pressure can develop if forceful suction is applied (causing patient pain)
    • Ethyl ether: does not result in clearing of fluid
    • Centrifugation: cloudiness persists
    • Cholesterol: always very high (>200 mg/dL)
    • Triglyceride: can occur in some cases of pseudochylothorax (but this is not characteristic)
    • Microscopy: cholesterol crystals can be seen (diagnostic)
      [Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration 1991; 58: 294–300]
    • AFB Cultures: should always be sent

Cllinical

  • Symptoms of Pleural Effusion
  • Complicating Infections:
    • Reactivation [[Tuberculosis]]
    • Aspergillosis
    • Other Fungal Infections
  • Complicating [[Bronchopleural Fistula]] or Pleurocutaenous Fistula

Treatment

  • xxx

References

  • ERJ May 1, 1997 vol. 10 no. 5 1157-1162
  • Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration 1991; 58: 294–300