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TREATMENT OF A NEWBORN WITH CHYLOTHORAX,
CHYLOPERICARDIUM AND CHYLOPERITONEUM
Agadjanova Shaira Khalilovna
Scientific supervisor:
Head of the department of pediatrics and neonatology
of the faculty, associate professor, ASMI
Shakhobiddinova Nodirabegim Khabibullo kizi
Independent researcher: ASMI
https://doi.org/10.5281/zenodo.13933193
Abstract.
The thesis presents a clinical case of successful conservative
treatment of a premature newborn with simultaneously developed chylothorax,
chylopericardium and chyloperitoneum. The nature of the effusion is confirmed
by biochemical studies and the predominance of lymphocytes. Intensive care
included long-term parenteral nutrition, octreotide with increasing doses,
artificial ventilation and fasting.
Kеywоrds:
neonates, chyloperitoneum, chylothorax, intensive care,
chylopericardium, octreotide.
INTRОDUСTIОN
Accumulation of lymphatic fluid in the pericardium, pleural or abdominal
cavities is a rare disease in the neonatal period with an incidence of 1 case per
15,000 births [1]. Traumatic (iatrogenic), spontaneous and congenital chylous
effusion are distinguished. Most often in clinical practice one can see chylothorax
and, less often, chyloperitoneum [1, 2]. The occurrence of chylopericardium in
newborns, according to literary data, refers to isolated observations [3, 4].
MАTЕRIАLS АND MЕTHОDS
Boy Sh. from the 9th pregnancy, which proceeded with the threat of
termination in the I-III trimesters, 4 operative deliveries at a gestational age of 30-
31 weeks. The mother's medical history includes a genetic form of thrombophilia
and chronic arterial hypertension. Assessment on the Apgar scale is 4/6 points,
birth weight is 1828 g, length is 42 cm, head circumference is 30 cm, chest
circumference is 26 cm. Immediately after birth, the child required artificial
ventilation of the lungs (ALV), surfactant was administered endotracheally. In the
intensive care unit, artificial ventilation was performed, infusion and antibacterial
therapy was prescribed, trophic nutrition was started, a central venous
percutaneous catheter was installed through the lower limb. On the 4th day of life,
the child's condition worsened: worsening respiratory failure, bronchospasm
attacks with cyanosis. X-ray and ultrasound examination (US) revealed right-sided
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
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hydrothorax. The boy was fitted with a pleural drain, which yielded 70 ml of milky
fluid. Laboratory tests confirmed the chylous nature of the effusion.
RЕSULTS АND DISСUSSIОN
Octreotide therapy was administered for 20 days with the dose being
increased to 10 mcg/kg/h. The child was given a course of intravenous
immunoglobulin, repeated transfusions of albumin, red blood cell mass, and
fresh frozen plasma (see figure).
At the age of 31 days, the child was extubated, and CPAP respiratory
support was administered for 5 days. On the 47th day, enteral feeding with
Pregestimil mixture was started with a starting dose of 1 ml/kg/h with gradual
expansion. At the age of 2 months 10 days, the boy was discharged home
weighing 2640 g.
The etiology and pathogenesis of spontaneous chylous effusion in
newborns have not been fully elucidated. A number of literary sources suggest a
theory of delayed maturation or hypoplasia of the milk capillaries, the walls of
which allow lymph to pass through. The completion of the ontogenesis of the
lymphatic system after the birth of the child explains cases of spontaneous
recovery during the first months of life [2]. Other sources associate the
occurrence of chylothorax with birth trauma, due to damage to the main
lymphatic duct and fluid leakage into the pleural cavity [3]. In half of the cases,
chylothorax is present immediately after birth, less often it appears during the
first week of life. More often, chylothorax, chylopericardium or peritoneum are
found in premature babies [3].
The main diagnostic criteria for chylous effusion are laboratory markers:
triglycerides >1.1 mmol/l, total cell count >1000 per ml with a predominance of
lymphocytes of more than 80% [1]. The predominance of lymphocytes is the
most important diagnostic criterion, since in newborns who did not receive
enteral nutrition, triglycerides do not increase and the fluid does not have a
characteristic milky color. In our observation, all samples contained
predominantly lymphocytes, and the fluid from the pleural cavity obtained
during the first puncture had a milky color. Due to the small number of
observations, there is no generally accepted protocol for the management of
newborns with chylous effusion. Therapy for this pathology begins with
conservative methods. In the absence of a positive effect within 2-5 weeks,
surgical interventions are indicated [4]. First of all, a pleural puncture is
performed and/or a pleural drainage is installed to evacuate the fluid, eliminate
respiratory distress and conduct diagnostics. Accumulation of chylous fluid in
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
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the pericardial cavity is a life-threatening condition with a high mortality rate,
requiring immediate pericardiocentesis. If the chylopericardium persists, a
pericardial drainage is installed. To reduce lymph production, a diet with the
complete exclusion of fats and enriched with medium-chain triglycerides is
indicated, taking into account the peculiarities of lipid metabolism. Absorption
of fatty acids in the small intestine depends on the length of the carbohydrate
chain. Short- and medium-chain fatty acids are transported by simple diffusion
into the intestinal epithelium, bypassing the lymph. Long-chain fatty acids form
transport complexes with bile acids. These complexes are called choleic acids. In
this form, fatty acids pass through the membrane of the intestinal epithelium
with subsequent resynthesis and formation of chylomicrons, which, after
absorption through the lymphatic pathways, enter first into the thoracic
lymphatic duct and then into the circulatory system.
СОNСLUSIОN
Simultaneous accumulation of chylous effusion in the pericardium, pleural and
abdominal cavities is an extremely rare observation in the neonatal period.
Treatment of this pathology is a long and complex process; there is no generally
accepted protocol. In this observation, conservative therapy, consisting of long-
term total parenteral nutrition, cancellation of enteral loading and the use of
octreotide, eliminated the lymph leakage and led to a complete recovery of the
child.
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