Idiopathic Chylothorax and Chylous Ascites Presenting as Discharge Per Vaginum Treated with Pleurodesis

Concomitant chylothorax and chylous ascites is a rare clinical phenomenon. We report the case of an adult-onset chronic idiopathic chylothorax and chylous ascites presenting with a chylous vaginal discharge which failed conservative treatment. This 61-year-old woman presented with a 2-year history of cough, dyspnoea, weight loss and general malaise, with later onset chylous vaginal secretion and abdominal distension. CT imaging confirmed the diagnosis of bronchiectasis, a large left pleural effusion and ascites, and pleurocentesis and ascetic taps confirmed the fluid as chyle. Known causes of chylothorax and/or chylous ascities include trauma, infection, malignancy, lymphangiodysplasia, lymphangioleimyomatosis (LAM), systemic lupus erythaematosis (SLE) and sarcoidosis. CT, MRI, mammography, lymphangioscintigraphy, bronchoscopic biopsies, endoscopy, laparoscopy and serology excluded all known causes. In an attempt to minimise the malnutrition and immunosuppression resulting from loss of large volumes of fluid, protein, immunoglobulins and lymphocytes, all conservative options were trialled. Unfortunately however, a fat-free diet with medium chain triglyceride (MCT) supplements, pleural and peritoneal drainage, somatostatin, octreotide and total parental nutrition (TPN) all failed to have a clinical impact. She proceeded to having a left video-assisted thoracoscopic (VATS) drainage of chylothorax and talc pleurodesis. The operation was successful in treating the chylothorax, and 6-month follow-up has shown no recurrence.