A 23-year-old man presented with diffuse swelling in the left half of the neck and the left half of the chest of 4 weeks' duration and gradual onset of breathlessness of 1 week duration. He also complained of early satiety and unquantified weight loss. He was a farmer by occupation, did not smoke or drink alcohol and did not have any significant past medical history. On examination, he was afebrile and normotensive, with respiratory rate of 26 breaths/min and a pulse rate of 98 beats/min. His neck swelling was a diffuse lymphedema, extending to the upper chest, up to the mammary area. The jugular venous pressure was not elevated and there was no erythema, tenderness or elevation of local temperature over the swelling. The respiratory system examination revealed findings consistent with left pleural effusion. The rest of the physical examination was unremarkable.
Investigations showed a hemoglobin count of 13.7 g/dL, leukocyte count of 8000 cells/cm3 with 78% neutrophils and a platelet count of 2.1 x 105/L. His liver function tests showed a total protein of 5.5 gms/dL, albumin of 2.7 gm/dL, normal transaminases and alkaline phosphatase of 1848 U/L. His serum creatinine was 0.8 mg/dL and lactic acid dehydrogenase (LDH) was 203 U/L (normal 140-280 U/L). Chest radiography showed a large left-sided pleural effusion. Diagnostic pleurocentesis revealed milky white pleural fluid, with a cell count of 708/cm3 and differential count of 98% lymphocytes and 2% neutrophils. The fluid was consistent with an exudative effusion (by Light's criteria), with protein of 3.4 gm/dL, albumin of 2.4 gm/dL and LDH of 172 U/L. The other pleural fluid characteristics were glucose of 90 mg/dL, adenosine deaminase (ADA) of 5.8 U/L, amylase of 18 U/L, triglycerides of 274 mg/dL and cholesterol of 104 mg/dL. The pleural fluid analysis was suggestive of chylothorax. Cytology was negative for malignant cells in the pleural fluid and the gram stain revealed no microorganisms.
An appropriate low-fat diet for chylothorax was initiated, with most fats in the form of medium-chain triglycerides. He was also started on octreotide to reduce chyle formation. Intercostal tube (ICD) insertion and drainage was performed to relieve his grade IV breathlessness. Three hundred milliliters to 400 mL of fluid was drained per day during the first 6 days of hospitalization. A search for the cause of chylothorax was undertaken. The patient denied any history of recent trauma or abdominothoracic surgery. There was no history of any febrile illness suggestive of tuberculosis. A computed tomogram (CT scan) of the chest showed moderate lymphangitis in the left lung, left-sided pleural effusion, minimal right-sided pleural effusion and minimal ascites [Figure 1]. A CT scan of the neck region revealed multiple enlarged left submandibular, posterior triangle and supraclavicular lymph nodes, the largest measuring 2.2 cm x 1.3 cm [Figure 2]. The left internal jugular vein was narrowed by 80% as compared with the right jugular vein. This, along with the lymphangitis, was concluded as the cause of chylothorax.
Ultrasound-guided fine needle aspiration of the neck lymph node was suggestive of adenocarcinoma [Figure 3]. As part of the work-up for malignancy, his carcinoembryonic antigen was elevated with a level of 11.91 ng/mL (normal 0.2-3.8).
Upper gastrointestinal endoscopy showed an ulcerated growth with everted margins measuring 2 cm x 2 cm in the posterior part of the stomach [Figure 4]. Biopsy of the ulcer confirmed it to be signet ring cell adenocarcinoma [Figure 5]. A diagnosis of gastric adenocarcinoma with metastasis to neck nodes was made. The chylous drain reduced to 100 mL/day after the first week. He was offered chemotherapy, which he wished to receive in his home town. The patient was discharged home at his request after ICD removal. On further telephonic follow-up, it was revealed that the patient expired 4 months after diagnosis after receiving alternative medicines.