Chylothorax in a pediatric patient secondary to stab wound

Abstract

Thoracic duct injury is usually the consequence of direct trauma following thoracic surgery, with external trauma mechanisms being exceptional in the pediatric population. Massive chylothorax requires pleural drainage and, when it presents clinical decompensation, it may require surgical repair of the thoracic duct injury as well.

Objective: To report a case of chylothorax of uncommon cause in pediatrics, and to describe how efficient but conservative management allowed complete recovery.

Clinical Case: A 10-year-old male patient, without previous clinical history, suffered from a stab wound to the left supra-clavicular region. Three days after the incident, due to respiratory distress, he was diagnosed with left massive pleural effusion which required tube thoracostomy drainage. The milky appearance and the presence of chylomicrons in the drained fluid oriented the diagnosis towards a chylothorax. The patient was admitted to the pediatric intensive care unit and received treatment with intravenous (IV) octreotide and a low long-chain triglyceride diet, supplemented with medium-chain triglyceride oil. Despite the initial improvement, a high chyle output persisted, requiring immunoglobulins and albumin replacement. After optimizing conservative management with fasting, parenteral nutrition for 15 days, octreotide at the maximum dose, and respiratory physiotherapy, a complete recovery was achieved, preventing the need for surgical intervention.

Conclusion: Chylothorax caused by penetrating trauma is a rare condition in the pediatric population that requires customized management. Surgical repair of the thoracic duct is an aggressive surgery and currently, there is limited expertise for the pediatric patient. Adequate conservative management may result in complete recovery, as it was described in this case report.