Clinical presentation, diagnosis and management of cholesterol effusions
- John E Heffner, MD
John E Heffner, MD
- Professor of Medicine
- Oregon Health & Science University
- Providence Portland Medical Center
Cholesterol pleural effusions (also called chyliform effusion or pseudochylothorax) are uncommon and are usually seen in the setting of chronic pleural inflammation or infection of greater than five years duration, although shorter durations have also been reported [1-5]. By definition, they contain a high concentration of cholesterol, giving them their characteristic turbid or milky white appearance. Although similar in gross appearance, the milky-appearing fluid in a chylothorax contains a high concentration of triglycerides, most commonly from disruption or obstruction of the thoracic duct.
The diagnosis and management of cholesterol pleural effusions will be reviewed here. The etiology, clinical presentation, diagnosis, and management of chylothorax and general issues regarding the evaluation and management of pleural effusions are discussed separately. (See "Etiology, clinical presentation, and diagnosis of chylothorax" and "Mechanisms of pleural liquid accumulation in disease" and "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Imaging of pleural effusions in adults".)
CHOLESTEROL EFFUSION VERSUS CHYLOTHORAX
Cholesterol effusions and chylothoraces both classically have a milky or opalescent appearance. However, their etiologies and therapy differ, making it important to distinguish them.
●Cholesterol effusions (also known as pseudochylothoraces or chyliform effusions) contain a high concentration of cholesterol. These effusions typically develop in patients with thickened and sometimes calcified pleural surfaces in the setting of chronic pleural inflammation [6,7], although they have been reported without pleural thickening in patients with rheumatoid arthritis [2,8].
●Chylothoraces, by comparison, are much more common and contain a high concentration of triglycerides in the form of chylomicrons [1,9-11]. A chylothorax arises when lymph fluid from the thoracic duct or other lymphatic channels accumulates in the pleural space due to disruption or obstruction. (See "Etiology, clinical presentation, and diagnosis of chylothorax".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Garcia-Zamalloa A, Ruiz-Irastorza G, Aguayo FJ, Gurrutxaga N. Pseudochylothorax. Report of 2 cases and review of the literature. Medicine (Baltimore) 1999; 78:200.
- Wrightson JM, Stanton AE, Maskell NA, et al. Pseudochylothorax without pleural thickening: time to reconsider pathogenesis? Chest 2009; 136:1144.
- Nogueras C, Monteagudo M, Vila M, et al. Recent-onset tuberculous pleurisy presenting as pseudochylothorax. Am J Med 2002; 113:166.
- Ryu JH, Tomassetti S, Maldonado F. Update on uncommon pleural effusions. Respirology 2011; 16:238.
- Lama A, Ferreiro L, Toubes ME, et al. Characteristics of patients with pseudochylothorax-a systematic review. J Thorac Dis 2016; 8:2093.
- COE JE, AIKAWA JK. Cholesterol pleural effusion. Report of 2 cases studied with isotopic techniques and review of the world literature. Arch Intern Med 1961; 108:763.
- Hillerdal G. Chyliform (cholesterol) pleural effusion. Chest 1985; 88:426.
- Muresan C, Muresan L, Grigorescu I, Dumitrascu DL. Chyliform effusion without pleural thickening in a patient with rheumatoid arthritis: A case report. Lung India 2015; 32:616.
- Roy PH, Carr DT, Payne WS. The problem of chylothorax. Mayo Clin Proc 1967; 42:457.
- Hillerdal G. Chylothorax and pseudochylothorax. Eur Respir J 1997; 10:1157.
- Agrawal V, Sahn SA. Lipid pleural effusions. Am J Med Sci 2008; 335:16.
- Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration 1991; 58:294.
- Prakash, UBS. Chylothorax and pseudochylothorax. Eur Respir Mon 2002; 7:249.
- Thewjitcharoen Y, Poopitaya S. Paragonimiasis presenting with unilateral pseudochylothorax: case report and literature review. Scand J Infect Dis 2006; 38:386.
- Inoue Y, Kawaguchi T, Yoshida A, et al. Paragonimiasis miyazakii associated with bilateral pseudochylothorax. Intern Med 2000; 39:579.
- Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31:743.
- Carel RS, Schey G, Bruderman I. Chyliform pleural effusion. An unusual manifestation of hepatothoracic echinococcus cysts. Chest 1975; 68:598.
- Jujo T, Suda A, Yahaba M, et al. [Paragonimiasis Westermani associated with pseudochylothorax]. Nihon Kokyuki Gakkai Zasshi 2009; 47:890.
- Dainichi T, Nakahara T, Moroi Y, et al. A case of cutaneous paragonimiasis with pleural effusion. Int J Dermatol 2003; 42:699.
- Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii4.
- Shen PU, Blair JL. Cholesterol crystals causing falsely elevated automated cell count. Am J Clin Pathol 2006; 125:358.
- Minh VD, Engle P, Greenwood JR, et al. Pleural paragonimiasis in a Southeast Asia refugee. Am Rev Respir Dis 1981; 124:186.
- Hiratsuka T, Kodama T, Nakamura F. [Paragonimiasis westermani with repeated pleural effusion and diagnosed by detecting parasite eggs in pleural effusion]. Nihon Kokyuki Gakkai Zasshi 2007; 45:49.
- Johnson JR, Falk A, Iber C, Davies S. Paragonimiasis in the United States. A report of nine cases in Hmong immigrants. Chest 1982; 82:168.
- Song JW, Im JG, Goo JM, et al. Pseudochylous pleural effusion with fat-fluid levels: report of six cases. Radiology 2000; 216:478.
- Staats BA, Ellefson RD, Budahn LL, et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980; 55:700.
- Tanijiri T, Yonezu S, Torii Y, et al. [Paragonimus westermani infection confirmed by the detection of Paragonimus ova in the sputum with bilateral pleural effusion]. Nihon Kokyuki Gakkai Zasshi 2009; 47:1131.
- Sassoon CS, Light RW. Chylothorax and pseudochylothorax. Clin Chest Med 1985; 6:163.
- GOLDMAN A, BURFORD TH. Cholesterol pleural effusion: A report of 3 cases with a cure by decortication. Dis Chest 1950; 18:586.
- CHOLESTEROL EFFUSION VERSUS CHYLOTHORAX
- CLINICAL FEATURES
- Physical examination
- Laboratory testing
- Pleural fluid analysis
- Testing for tuberculosis
- Testing for paragonimiasis
- Pulmonary function testing
- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
- Treating the underlying disease process
- Therapeutic thoracentesis
- Other management interventions
- SUMMARY AND RECOMMENDATIONS