Images in Clinical Medicine
Chylous Effusion in Hodgkin's Disease
N Engl J Med 1998; 339:1515November 19, 1998
- Article
Figure 1 A 54-year-old man who had had stage IVA follicular small-cleaved-cell lymphoma for 10 years was admitted with a 3-week history of progressive cough, shortness of breath, fatigue, and night sweats. When his disease was first discovered he had been treated with prednisone, doxorubicin, cyclophosphamide, and etoposide, followed by cytarabine, bleomycin, vincristine, and methotrexate with leucovorin rescue. He subsequently received intermittent courses of cyclophosphamide and prednisone. The chest film revealed a stable right pleural effusion and a new, ill-defined left suprahilar mass. A staging computed tomographic scan showed a pleural effusion with a fluid–fluid interface (arrowhead) that was associated with new pulmonary parenchymal disease, progressive adenopathy, and extranodal involvement of the liver, spleen, and gastrointestinal tract. The chylous effusion formed a density gradient, presumably as a result of the separation of chylomicrons from the aqueous phase, resulting in a “dense and denser” appearance at the interface. The pleural fluid, which was viscous and had a white, “yogurt-like” appearance, contained 1320 mg of triglycerides per deciliter (15 mmol per liter) and 2.2 g of protein per deciliter, with rare white cells and red cells. The results of histologic examination of an inguinal lymph node were consistent with the presence of lymphocyte-depletion Hodgkin's disease. On the fifth day of standard chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine, a massive upper gastrointestinal hemorrhage occurred as a result of erosion into a large gastric mass, followed by hypotension and multiorgan failure. The patient died 48 hours later.
Philippe C. Bishop, M.D.
Patrick C. Elwood, M.D.
National Institutes of Health, Bethesda, MD 20892
