Left-sided chylothorax following ipsilateral hemithoracic stab wound in a 20-year-old man: the first case report

{"Background": "Chylothorax is defined as the accumulation of chyle\u2014a lymphatic emulsion rich in triglycerides, proteins, and leukocytes\u2014in the pleural space. It is classified into traumatic and nontraumatic categories, with traumatic causes being less common overall. Penetrating traumas, particularly right-sided injuries that damage the thoracic duct (TD), are a well-recognized cause. Iatrogenic injury during cardiothoracic or oncologic surgery has surpassed penetrating trauma as the most prevalent traumatic cause. The thoracic duct is the main lymphatic trunk, typically ascending through the aortic hiatus and draining into the left subclavian-internal jugular vein junction. Anatomical variations in TD branching and tributaries are known but not fully characterized. To the authors' knowledge, no prior case of left-sided chylothorax from an isolated ipsilateral stab wound has been reported.", "Methods": "This is a single case report following the Surgical CAse REport (SCARE) criteria. A 20-year-old male of low socioeconomic status presented to the emergency department after a sharp object assault to the chest. On primary survey, he was spontaneously speaking but in respiratory distress (rate 30/min) with use of accessory muscles. Breath sounds were reduced on the left side, jugular veins were bulging, blood pressure was 100/60 mmHg, and there was a stab wound <2 cm in the left fifth intercostal space without active bleeding. Subcutaneous emphysema was present on the same side. No muffled heart sounds or concurrent injuries were found. Oxygen and intravenous crystalloids were administered, and a left-sided chest tube was inserted emergently. Large amounts of air and a milky-bloody exudate were drained, reaching approximately 1 liter per day. The chest tube was replaced, total parenteral nutrition was initiated, and the patient was kept nil per os from the first hour. Biochemical analysis of the drained fluid confirmed its lymphatic nature. The patient was followed weekly for 1 month after discharge.", "Key Results": "Biochemical analysis of the pleural exudate revealed: glucose 101 mg/dL, protein 3.1 mg/dL, LDH 739 U/L, triglycerides 313 mg/dL, albumin 2.5 g/dL, amylase 32.1 U/dL, WBC 1200/\u03bcL, and RBC 20,000/\u03bcL. The triglyceride concentration of 313 mg/dL (well above the diagnostic threshold of 110 mg/dL) confirmed chylothorax. Chyle output was approximately 1 L/day for the first 5 days, then gradually decreased to 250-300 mL/day until it cleared sufficiently for chest tube removal. The patient's 1-month follow-up was uneventful.", "Clinical Implications": "This case demonstrates that left-sided chylothorax can occur from an isolated ipsilateral stab wound, likely due to anatomical variation of the thoracic duct or its intrathoracic tributaries. It underscores that penetrating trauma to either hemithorax can cause chylothorax, not only right-sided injuries as typically expected. Conservative management with tube thoracostomy and dietary restriction (nil per os with total parenteral nutrition) was sufficient for resolution, avoiding the need for surgical or percutaneous intervention. The authors note that if conservative care fails, lymphangiography and thoracic duct embolization are now preferred over older techniques. This report adds to the understanding of TD anatomical variation and supports a conservative first-line approach for traumatic chylothorax."}