Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 61, Num. 8, 2007, pp. 476-477

Indian Journal of Medical Sciences, Vol. 61, No. 8, August, 2007, pp. 476-477

Letter To Editor

A rare cause of chylo-pneumothorax in a preterm neonate

Kairamkonda VenkateshR

Neonatal Intensive Care Unit, Leicester Royal Infirmary, Leicester LE1 5WW
Correspondence Address:2d, Blakeshay close, Bradgate heights, Leicester, LE3 9QZ venk14@yahoo.co.uk

Code Number: ms07078

Sir,

A 565-g male neonate born at 27 weeks gestation was ventilated for respiratory distress syndrome. The initial chest radiograph showed features suggestive of surfactant deficient lung disease. The neonate was hemodynamically stable and required minimal ventilation. He was commenced on total parenteral nutrition from day 1 and was tolerating 6 hourly advancement of breast milk given via orogastric tube. He unexpectedly deteriorated on day 3 with sudden bradycardia (heart rate < 60/min) and desaturation (Spo2 < 30 on 100% Fi02) not responding to endotracheal tube change, chest compressions and adrenaline. Transillumination of the chest suggested a right pneumothorax. Emergency right tube thoracostomy drained milky fluid with immediate improvement in the cardiorespiratory parameters. The pleural fluid analysis revealed leukocyte count 15 x 10 ⁹ /L, lymphocyte fraction> 90%, triglycerides 240 mg/dl; and gram staining was clear. A presumptive diagnosis of chylothorax was made. Post-thoracostomy radiograph without the orogastric tube, due to accidental removal during emergency intubation, confirmed fluid and air in the right pleural space [Figure - 1]. Total parenteral nutrition was discontinued, and orogastric-tube feeding with medium-chain triglyceride milk was commenced. He developed worsening respiratory parameters (ventilatory pressures, oxygen, respiratory rate and blood gas) 18 h after right thoracostomy tube. A repeat radiograph [Figure - 2] revealed the orogastric feeding tube tip in the right pleural space, confirming esophageal perforation. The neonate was kept nil by mouth, commenced on antimicrobials and total parenteral nutrition. He was established to full enteral breast-milk feeds after 7 days without re-accumulation of the pleural fluid.

Iatrogenic perforation of the esophagus of a neonate is an uncommon emergency and can be fatal. It usually presents acutely with pneumothorax. ^[1],[2] This is the first case report to highlight that traumatic esophageal perforation in the preterm neonate can present with acute cardiorespiratory decompensation due to chylo-pneumothorax. Transillumination of the chest aids in the diagnosis of pneumothorax in neonates. ^[3],[4] The commonest site of perforation is cervical esophagus, though no part is immune. ^[1] The site of perforation in our case involves the thoracic esophagus, which is unusual. Repeated attempts at intubation, naso-gastric intubation, vigorous suctioning, direct trauma due to probing fingertip or attempts at laryngoscopy have been implicated in its etiology. The most likely cause in our case may be orogastric tube placement. The right chylothorax may have developed subsequently due to a combination of accidental milk feeds (breast and medium-chain triglyceride) and chyle. ^[5] The accumulation of chyle may be due to the traumatic damage to the thoracic duct following right chest-tube placement [Figure - 2].

To conclude, high index of suspicion is needed to diagnose esophageal perforation which may present as chylo-pneumothorax in a preterm neonate.

References

Copyright 2007 - Indian Journal of Medical Sciences

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