Scientific Letter
Sneeze-induced chylothorax
Quilotórax inducido por estornudo
Sonia Fornés, Silvia Bielsa, José Manuel Porcel
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Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
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Note the presence of calcification foci in the left mass (arrows). C) Axial CT image of the chest clearly showing the different attenuation characteristics of the mediastinal masses: the right mass (white asterisk) has a mean attenuation of 83 Hounsfield units while the left mass (black asterisk) has a mean attenuation of 54 Hounsfield units, suggesting an independent origin. D) and E) Axial (D) and coronal (E) PET/CT images showing the different metabolic activity of the two mediastinal masses (greater FDG uptake by the left mass [6.1, black asterisk] than by the right mass [3.6, white asterisk]), suggesting two independent tumors. F) Percutaneous biopsy sample of the left mediastinal mass showing neoplastic proliferation of epithelial cells surrounded by fibrous tissue and scant lymphocytes, associated with type B3 thymoma (hematoxylin and eosin). 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The only case of chylothorax attributable to sneezing published to date resolved rapidly within a few days.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report, however, another similar case with a course that was not so favorable and required various interventional therapeutic techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 71-year-old man consulted for progressive dyspnea of two weeks’ duration, with no general symptoms, orthopnea, fever, or previous trauma. His history was significant for arterial hypertension, permanent non-valvular atrial fibrillation, and aortic valve replacement with a mechanical prosthesis performed 8 years earlier. He was receiving treatment with acenocoumarol. Chest X-ray revealed left pleural effusion occupying half of the hemithorax. Thoracentesis showed a milky fluid with the following characteristics: leukocytes 1,875/μL (95% lymphocytes), proteins 3.8 g/dL (serum 6.91 g/dL), lactate dehydrogenase 373 U/L (serum 685 U/L), triglycerides 1,203 mg/dL (serum 93 mg/dL), cholesterol 62 mg/dL (serum 197 mg/dL), normal flow cytometry, and cytological studies negative for malignancy. A chest-abdominal CT only showed left pleural effusion with no pleural thickening or enlarged lymph nodes. Intranodal lymphangiography showed extravasation of contrast material (lipiodol) into the left pleural cavity (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was interviewed again and reported several fits of intense sneezing during the days before the appearance of the present symptoms, an event confirmed by his wife. He required two therapeutic thoracenteses of 1 L and 1.25 L over the course of two weeks, so a tunneled pleural catheter (TPC) was inserted for controlled drainage at home. After two weeks of intensive (daily) drainage via the TPC and radiological confirmation of lung re-expansion, 4 g of talc in solution (slurry) were instilled through the TPC. A low-fat diet was also recommended and octeotride (50 mcg/12 h sc) was prescribed, which continued for six weeks. After 10 weeks of talc instillation through the TPC and when three successive drainage procedures yielded less than 50 mL, the TPC was withdrawn. No radiological recurrence of effusion has been observed after 1 year of follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This would be the second case of sneezing-induced chylothorax described in the medical literature, according to a search in the PubMed database from its inception until November 16, 2020, using the terms «<span class="elsevierStyleItalic">chylothorax or thoracic duct leak</span>» and «<span class="elsevierStyleItalic">sneeze or sneezing</span>». The previously reported case was a 60-year-old woman who developed bilateral chylothorax after a violent sneeze.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Along with the dietary restriction of fats, the patient required the placement of endopleural tubes, one in each hemithorax, which could be removed after two and five days, respectively. Absence of effusion was confirmed on a follow-up X-ray at 3 months. Given the rapid resolution of the process in less than a week with the described treatment, chylothorax due to sneezing was believed to have a good prognosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, in our case, the patient required three and a half months of successive and simultaneous procedures (therapeutic thoracentesis, low-fat diet and octeotride, insertion of a TPC, pleurodesis with talc) to definitively resolve the chylothorax. Lymphangiography, which by itself can reduce the leakage of chyle in some patients, was ineffective in our patient. Therefore, we cannot confirm that strictly conservative treatment can resolve all cases of this rare entity. The left location of the chylothorax indicates that the thoracic duct must have been damaged above the fifth or sixth thoracic vertebrae. Hypothetically, the pathogenesis of chylothorax would be the acute and intense increase in intrathoracic pressure during the sneeze, which would lead to a micro-rupture of the thoracic duct and the corresponding leakage of chyle into the pleural space. In the medical literature, cases of spontaneous “idiopathic” chylothorax have been described, some of which, in view of their temporal relationship and exclusion of other causes, were finally attributed to physical activity,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> energetic cough,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or childbirth,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> all with the common link of an increase in intrathoracic pressure. Our case underlines the importance of obtaining a directed history to suggest the etiology of chylothorax of apparently uncertain origin. However, due to the exceptional nature of the association between sneezing and chylothorax, it is not possible to infer a uniform course in these cases.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fornés S, Bielsa S, Porcel JM. Quilotórax inducido por estornudo. Arch Bronconeumol. 2021;57:558–559.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 750 "Tamanyo" => 117802 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronal CT slice showing lipiodol injected during intranodal lymphangiography in the inguinal lymph ducts, thoracic duct, and left pleural cavity.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Derrames pleurales benignos persistentes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. 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Fernández Cofrades" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1157/13117050" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2008" "volumen" => "208" "paginaInicial" => "207" "paginaFinal" => "208" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18381013" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute neck swelling and chest pain after forceful coughing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J. Vidri" 1 => "T. Ng" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamasurg.2017.2623" "Revista" => array:6 [ "tituloSerie" => "JAMA Surg" "fecha" => "2017" "volumen" => "152" "paginaInicial" => "976" "paginaFinal" => "977" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28832873" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chylothorax after childbirth" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.K. Cammarata" 1 => "R.E. Brush Jr" 2 => "R.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 46 | 19 | 65 |
| 2024 September | 53 | 21 | 74 |
| 2024 August | 69 | 55 | 124 |
| 2024 July | 52 | 19 | 71 |
| 2024 June | 61 | 27 | 88 |
| 2024 May | 68 | 33 | 101 |
| 2024 April | 43 | 15 | 58 |
| 2024 March | 39 | 15 | 54 |
| 2024 February | 35 | 29 | 64 |
| 2024 January | 36 | 25 | 61 |
| 2023 December | 30 | 24 | 54 |
| 2023 November | 45 | 16 | 61 |
| 2023 October | 41 | 29 | 70 |
| 2023 September | 42 | 33 | 75 |
| 2023 August | 43 | 31 | 74 |
| 2023 July | 47 | 25 | 72 |
| 2023 June | 32 | 16 | 48 |
| 2023 May | 47 | 30 | 77 |
| 2023 April | 45 | 23 | 68 |
| 2023 March | 77 | 27 | 104 |
| 2023 February | 45 | 28 | 73 |
| 2023 January | 54 | 21 | 75 |
| 2022 December | 56 | 24 | 80 |
| 2022 November | 60 | 29 | 89 |
| 2022 October | 89 | 32 | 121 |
| 2022 September | 58 | 29 | 87 |
| 2022 August | 48 | 43 | 91 |
| 2022 July | 45 | 44 | 89 |
| 2022 June | 30 | 33 | 63 |
| 2022 May | 37 | 26 | 63 |
| 2022 April | 48 | 34 | 82 |
| 2022 March | 51 | 38 | 89 |
| 2022 February | 12 | 19 | 31 |
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