October 2022 Medical Image of the Month: Infected Dasatinib Induced Chylothorax-The First Reported Case

Figure 1. Upright PA chest radiograph (A) demonstrates a large left-sided pleural effusion with some lateral fluid suggesting loculation. Bedside ultrasound to guide thoracentesis (B) demonstrates multiple loculations within the effusion (arrowheads). Thoracentesis yielded 2 liters of milky white fluid (C).

Figure 2. Axial lung window (A) and soft tissue window (B) reconstructions from a chest CT with intravenous contrast performed following thoracentesis demonstrates a circumferential irregular left-sided pleural effusion with air space disease within the left lower lobe concerning for infection. A simple-appearing right-sided effusion is noted as well (*).

Case Report

A 45-year-old man with chronic myeloid leukaemia (CML) on dasatinib presented to the emergency department with a 2-week history of dry cough, worsening shortness of breath and left-sided chest pain that had worsened on the day of presentation. On examination, oxygen saturation was 98% on 2 L nasal cannula, respiratory rate 22 bpm, pulse 77 bpm, blood pressure 117/90 mmHg and his temperature was 37.9° C (100.2 F). Examination of the left chest showed no air entry and stony dull percussion note.

Laboratory results were significant for leucocytosis with a neutrophil count of 11.2, elevated CRP of 414, mildly elevated lactate of 1.1. Initial chest X-ray showed large left-sided pleural effusion and a small volume right effusion (Figure 1A). The patient was started on IV piperacillin /tazobactam, blood cultures were obtained and the dasatinib was held.

Ultrasound-guided left thoracentesis and drain placement was performed, on ultrasound the effusion demonstrated several loculations (Figure 1B). An 18Fr drain was inserted and 2L of white purulent/milky material fluid was drained (Figure 1C). Pleural fluid analysis showed abundant neutrophils, macrophages, lymphocytes and a few reactive mesothelial cells. Cytological analysis was negative for malignant cells. The fluid was exudative by Light’s criteria as total protein was 52.9 g/l and serum protein was 77 g/l with the ratio 0.68. Triglyceride level was 2.0 mmol/l and fluid cholesterol was 1.6 mmol/L indicative of chylothorax.

Over time, pleural cultures were positive for beta haemolytic Strep group C/G sensitive to penicillin G and erythromycin and both fungal and tuberculosis cultures were negative. Blood cultures were negative. Antimicrobial therapy was deescalated to Penicillin G. A subsequent chest CT (following intra-pleural fibrinolytic therapy) showed small left basal effusion with overlying consolidation and no occlusive lesion identified (Figure 2). After 9 days the pleural drain was removed, and the patient had no reaccumulation of their chylothorax. The patient remained clinically well and was discharged after a course of four weeks of antibiotics. At a 2 week follow up the patient was asymptomatic and had a normal physical exam. His inflammatory markers were back to normal CRP was 0.5 and WBC count was 6.5.

Discussion

Chylothorax is accumulation of chyle into the pleural space related to obstruction or disruption of the thoracic duct. It is a rare condition that may arise from diverse etiologies broadly categorized as traumatic or non-traumatic/spontaneous (1). Chylothorax is widely believed to be inherently bacteriostatic, with rare incidence of infected chylous effusions affecting a wide variety of patients with different causative organisms and a mostly benign course (2).

Dasatinib is a second-generation tyrosine kinase inhibitor that is recommended as the first-line therapy for newly diagnosed chronic myeloid leukaemia (CML) or acute lymphoblastic leukaemia (ALL) with positive Philadelphia chromosome (Ph+) or as an alternative for the failure of prior therapy for CML. Dasatinib is known to cause fluid retention which commonly presents as an exudative pleural effusion (3), chylothorax is rarely seen with 7 cases in total related to dasatinib use were published in the literature (4).

This is the first reported case of infected chylothorax among the population using dasatinib. Infected chylothorax in general is rare, affecting wide variety of patients with different organisms and mostly benign course (2). In this report the patient was stable on presentation and showed good response to antibiotics, chest drainage, holding of dasatinib and dietary fat restriction. Given the loculated appearance of the fluid the patient benefited from a dose of thrombolysis, which was reported as an option in such a scenario (5).

In patients with CML on dasatinib presenting with pleural effusion, the medication should be considered as one of the possible causes. Furthermore, infected chylothorax should be considered in the deferential diagnosis as a source of sepsis in patients presenting with a sepsis-like clinical picture and pleural effusion. The case also reflects the importance of bedside ultrasound in both clinically examining the patients and as a guide for thoracentesis and guidance for therapy.

Mortada Mohammed¹ MD MRCPI, Mohanad Abdelrahim² MD, Keshav Sharma³ MD MRCPI

¹Respiratory medicine registrar Wexford General Hospital, Wexford, Ireland

²Medical Senior House officer Wexford General Hospital, Wexford, Ireland

³Consultant Respiratory and General Medicine Physician, Wexford General Hospital, Wexford, Ireland

References

1. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010 Jan;104(1):1-8. [CrossRef] [PubMed]
2. Eubank L, Gabe L, Kraft M, Billheimer D. Infected chylothorax: a case report and review. Southwest J Pulm Crit Care. 2018 Aug 25;17(2):76–84. [CrossRef]
3. Keating GM. Dasatinib: A Review in Chronic Myeloid Leukaemia and Ph+ Acute Lymphoblastic Leukaemia. Drugs. 2017 Jan;77(1):85-96. [CrossRef] [PubMed]
4. Chen B, Wu Z, Wang Q, Li W, Cheng D. Dasatinib-induced chylothorax: report of a case and review of the literature. Invest New Drugs. 2020 Oct;38(5):1627-1632. [CrossRef] [PubMed]
5. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg. 2007 Aug;32(2):362-9. [CrossRef] [PubMed]

Cite as: Mohammed M, Abdelrahim M, Sharma K. October 2022 Medical Image of the Month: Infected Dasatinib Induced Chylothorax-The First Reported Case. Southwest J Pulm Crit Care Sleep. 2022;25(4):47-9. doi: https://doi.org/10.13175/swjpccs036-22 PDF

Medical Image of the Week: Fournier’s Gangrene with a Twist

Figure 1. A: Coronal view of abdominal CT scan showing extensive gas formation from the site of trauma (scrotum) ascending along fascial planes, encompassing abdominal wall and chest wall (arrows). B: Close up view of the scrotum and perineum showing tissue necrosis with gas formation. C: Sagittal view of the thoracic CT scan showing gas formation tracking along the chest wall and superior mediastinum (arrows).

Figure 2. Status post incision and debridement of scrotum and perineum.

A 37-year-old man presented with worsening left testicular pain, swelling and redness within 3 days of being poked by a safety-pin during foreplay. Over 24 hours, his left scrotum doubled in size with significant erythema, edema, crepitus and induration. Imaging of scrotum and legs revealed extensive gas formation extending to the retroperitoneum and ascending along fascial planes. Subcutaneous emphysema of abdominal wall, chest wall with mediastinal gas was noted. Investigation showed a shite blood cell count of 22,000 cells/mcL with 12% bands and HIV testing was negative. Intravenous vancomycin and ertapenem were administered on presentation followed by emergent bilateral debridement of the scrotum. Wound/tissue cultures grew methicillin sensitive Staphylococcus aureus, group B Streptococcus and anaerobic Bacteroides. Antibiotics were de-escalated to ciprofloxacin and metronidazole and the patient showed adequate recovery at 30 days of follow up.

Improved survival of Fournier’s gangrene can only be achieved by prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics.

Our case brings forward the act of piquerism, a paraphilia which led to rapidly progressive perineal tissue necrosis with bacterial synergism of non-clostridial micro-organisms causing extensive gas formation.

Padmastuti Akella, MD¹, Himmat Grewal MD¹, Imola Daniel MD²

¹Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA

²Division of Infectious Diseases, Saint Vincent Hospital, Worcester, MA

References 

1. Archer CB, Rosenberg WM, Scott GW, MacDonald DM. Progressive bacterial synergistic gangrene in patient with diabetes mellitus. J R Soc Med. 1984;77 Suppl 4:1-3. [PubMed]
2. Yasuda K, Hayashi M, Takeda N, Goshima E, Miura K. A survived case of diabetic nonclostridial gas gangrene and the review of the literatures on microbiological findings. Jpn J Med. 1986 May;25(2):171-4. [CrossRef] [PubMed]
3. Takazawa K, Otsuka H, Nakagawa Y, Inokuchi S. Clinical features of non-clostridial gas gangrene and risk factors for in-hospital mortality. Tokai J Exp Clin Med. 2015 Sep 20;40(3):124-9. [PubMed]
4. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-65. [CrossRef] [PubMed]

Cite as: Akella P, Grewal H, Daniel I. Medical image of the week: Fournier's gangrene with a twist. Southwest J Pulm Crit Care. 2018;17(1):28-9. doi: https://doi.org/10.13175/swjpcc083-18 PDF

Medical Image of the Week: Infected Emphysematous Bulla

Figure 1. Portable AP chest X-ray revealing dense opacity within the lingula of left lung.

Figure 2. Thoracic CT with contrast showing lobar consolidation with increased lucency compatible with emphysema.

Figure 3. (A) Chest CT one year prior demonstrating severe emphysema. (B) Chest CT on admission showing new fluid-filled bulla (red arrow) in the setting pneumococcal pneumonia.

A 65 year-old man with chronic obstructive lung disease (COPD), hypertension and alcohol abuse presented to the emergency department with complaints of feeling unwell and shortness of breath. He was tachycardic but otherwise hemodynamically stable, afebrile, and requiring 3 liters/min supplemental oxygen. Pertinent initial laboratory findings revealed a neutrophilic predominant leukocytosis (WBC 37.8 x 10³ micro/L) with lactic acidosis (2.7 mMol/L). Chest radiograph showed a dense opacity within the region of the lingula (Figure 1). Follow-up CT chest confirmed a consolidation likely representing lobar pneumonia in the setting of severe bullous emphysema (Figure 2). A large fluid-containing emphysematous bulla (Figure 3) was present which was not visualized one year prior. 

He was started on broad spectrum antibiotics after peripheral blood cultures were drawn which revealed Streptococcus pneumoniae. Broad spectrum antibiotics were discontinued and patient was started on intravenous ceftriaxone 2g every 24 hours. He improved clinically and was discharged home after 4 days.

Pneumococcal pneumonia remains the most common cause of community-acquired pneumonia and accounts for nearly 66% of all bacteremic pneumonias (1,2). Our patient had multiple risk factors for developing pneumococcal pneumonia including alcohol abuse, COPD, and history of cigarette smoking. Pneumococcal pneumonia often causes dense consolidation within the lung in a well-defined lobar or segmental distribution. In emphysema areas of lucency may be seen within the consolidation which may mimic other processes such as necrosis. The pathogenesis of fluid accumulation in an emphysematous bulla is not well understood but can be associated with severe lung infection (3). Percutaneous drainage is not recommended and bronchoscopy is not usually required unless there is another indication (3). Antibiotic therapy in those who are asymptomatic has not shown to add any benefit in resolution or preventing infection (3).

Norman Beatty MD¹, Kyle McKeown MPH², Kelly M. Hager MPH², and Stephen J. Scholand MD³

¹ Department of Medicine, Banner-University Medical Center South, Tucson, AZ USA

² University of Arizona College of Medicine, Tucson, AZ USA

³ Division of Infectious Diseases, Department of Medicine, MidState Medical Center, Meriden, CT USA

References

1. Torres A, Peetermans WE, Viegi G, Blasi F. Risk factors for community-acquired pneumonia in adults in Europe: a literature review. Thorax. 2013 Nov;68(11):1057-65. [CrossRef] [PubMed]
2. Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996 Jan 10;275(2):134-41. [CrossRef] [PubMed]
3. Chandra D, Rose SR, Carter RB, Musher DM, Hamill RJ. Fluid-containing emphysematous bullae: a spectrum of illness. Eur Respir J. 2008 Aug;32(2):303-6. [CrossRef] [PubMed]

Cite as: Beatty N, McKeown K, Hager KM, Scholand SJ. Medical image of the week: infected emphysematous bulla. Southwest J Pulm Crit Care. 2016;14(1):37-8. doi: https://doi.org/10.13175/swjpcc006-17 PDF