A team headed by Dr Praveen Kulkarni, Senior Consultant - Cardiology, Global Hospitals, Parel, Mumbai, successfully diagnosed and treated a case of Chylous Pericardial Effusion due to the high cholesterol in a 55-year-old male.
The patient underwent multiple procedures to correctly diagnose and treat his condition which was thought to be Tuberculosis in the duration of one and a half months following his first presentation due to loss of consciousness. The patient has recovered completely and is leading a normal life now.
Shrikant Pawar, 55 years, working in an automotive company, a known diabetic was admitted couple of months ago to a city hospital for shortness of breath and chest pain. On evaluation, he was diagnosed to have pericardial effusion, a condition where fluid accumulates around the heart. Pericardial Tapping, removing the fluid from the pericardial space, was done and on evaluation was attributed to Tuberculosis. He was put on Anti tubercular medications and discharged from the city hospital.
He visited the Neurologist at Global Hospitals, Parel, Mumbai, while being on Anti TB treatment as he was having recurrent loss of consciousness. The patient was referred to Dr Praveen Kulkarni as he had a history of pericardial effusion. A repeat 2 D Echo revealed pericardial effusion. Routine lab investigations were sent which showed elevated levels of cholesterol. As the patient had significant pericardial effusion, it was decided to drain the effusion (Pericardiocentesis) and hence a fine catheter was placed in the pericardial cavity and 400 ml of thick and milky white fluid was drained. It was initially thought that this fluid was pus, but it did not correlate well with his clinical condition as having 400 ml of pus around his heart would have made him extremely sick. Further, the drain was draining this thick white fluid in large quantities on a daily basis. Detailed analysis of the fluid revealed extremely high levels of cholesterol in the fluid and a diagnosis of Chylous Pericardial Effusion was arrived at.
Chylous pericardial effusion is a rare type of pericardial effusion that occurs when a chyle, a milky fluid that is a mixture of lymph and fat (fat and carbohydrates eaten by you are converted to Chyle and transported through the lymphatic channels, accumulates in the pericardial cavity, the sac surrounding the heart. This condition is caused by the obstruction of the thoracic duct, the largest lymphatic vessel in the body, which transports chyle from the gastrointestinal tract to the bloodstream. Additional tests and scans were done to rule out any malignancy, all of which including a PET scan were negative.
MR Lymphangiography was done to understand leaks. One of the lymph ducts was draining into the pericardial space due to an abnormal leak causing chylous pericardial effusion. A rare procedure was done to embolize (use of small coils to occlude flow) cysterna chylli through a puncture in the left arm, twice, showing initial response but eventually leading to reaccumulation. This was attributed to new leaky channel formations.
He was put on medium chain fatty acid foods to keep his cholesterol levels low, but despite this, he continued to lose weight and drain chyle from the pericardial catheter. After discussing with the CVTS Surgeon, it was decided to go ahead with a pleuro-pericardial window formation, as this surgery would be the definitive treatment as it would give a route for chyle to drain from pericardial space into the pleural space and thereon drain into the major vessels. This was performed using minimally invasive surgery (MICS) to ensure a faster recovery.
DR Praveen Kulkarni, Senior Consultant Cardiologist, Global Hospitals, Parel Mumbai, said, “Pericardial effusion means fluid accumulating around the heart. Typically, in the Indian setting tuberculosis (TB) is the leading cause. Other causes can be viral infections, certain malignancies, blood cancers like lymphoma, the spread of cancer into that space (metastasis), and certain autoimmune diseases. When we did the first 2D Echo on admission, there was still a significant amount of fluid in the pericardial space. It is a closed space so the fluid starts pressing on the chambers and the blood cannot be pumped up. The patient had a loss of consciousness due to low blood pressure and consequently less blood flowing into the brain which is called Cardiac tamponade. It is an emergency and life-threatening condition caused by fluid accumulation reaching dangerous levels. Pericardiocentesis was done and he was draining fluid on a daily basis. On evaluating the fluid, when the cholesterol levels were extremely high, we came to a diagnosis of Chylous Pericardial Effusion. This is a rare entity and is often misdiagnosed. During the course of the stay, he continued to lose weight drastically as the fluid that was being drained out was rich in fat and protein. He lost close to 15 kgs. After discussing with my surgical colleagues we gave the patient the option to undergo pleuropericardial window formation. This was conducted in a minimally invasive manner with a small incision under the ribcage. He was discharged after one and a half months. On follow-up, there was no fluid accumulation detected and he also regained weight. Not treating him promptly could have led to recurrence and possible catastrophe including death. There should be awareness among cardiologists and physicians treating such patients to keep the findings of this rare entity in mind while deciding the causes and line of treatment for the patients.”
“I had no knowledge about this unknown entity and suffered a lot for over 2 months. I am fine now and have resumed my daily routine with ease. I thank the doctors for the timely and correct diagnosis and treatment to save my life,” mentioned the patient Shrikant Pawar.
“With a commitment to Excellence and Innovation, Global Hospital has consistently set the standard for advanced medical care. This is a one-of-its-kind case handled with accuracy by our Clinical Team. We understand how significant it is for patients to receive the most comprehensive healthcare possible, and make every effort to offer only the best in expertise and service,” concluded Dr Vivek Talaulikar, Chief Executive Officer, Global Hospitals, Parel Mumbai.