Chylothorax as a manifestation of child abuse.
OBJECTIVE: Chylothorax presenting in a child without a well defined etiology may be a manifestation of child abuse. We recently observed a child with bilateral chylothoraces who demonstrated coexisting nonaccidental injuries. It is our intention to alert physicians to the association of chylothorax with nonaccidental trauma and review the prior medical literature. DESIGN: Case report. SETTING: Pediatric emergency department and intensive care unit. PATIENT: An 18-month-old female child who presented with respiratory distress and failure to thrive. INTERVENTIONS: Diagnostic and therapeutic thoracentesis. Skeletal survey and radionuclide bone scan. Nutritional support. OUTCOME MEASURES: Pleural fluid is characterized as chylous if it contains significant numbers of lymphocytes and lipid. Unexplained fractures of the ribs and long bones in varying stages of healing are considered nonaccidental. Failure to thrive may be considered nonorganic when nutritional support alone results in significant weight gain. RESULTS: Our patient presented with respiratory distress of one-week duration and failure to gain weight during the prior five months. The chest radiograph demonstrated bilateral pleural effusions, which were aspirated. The aspirate contained 1733 cells/mm3 (98% lymphocytes), which were lipid laden. The triglyceride concentration was 806 mg/dl. A skeletal survey demonstrated bilateral first rib, clavicle, and ulnar fractures. A radionuclide bone scan additionally revealed multiple vertebral body fractures. Nutritional support alone resulted in significant weight gain. The patient was reported to local authorities as having been abused. CONCLUSION: Child abuse should be considered as an etiology for cryptogenic chylothorax. Further studies should be undertaken in this circumstance to search for coexisting injuries, which may indicate nonaccidental trauma.