Thoracic Duct Laceration"

Contrast is present in the left pleural chest tube.
- It was not present on prior films.
- No contrast was introduced via this tube.
- Therefore, it drained contrast present in the left pleural space.
How did it get there?
Did you notice the small pneumothorax at the left lung apex?

Discussion:

Pleural fluid, if not introduced externally, may be:
- Blood -- e.g., s/p trauma.
- Cells -- e.g., due to malignancy.
- Fluid (transudate) -- e.g., CHF.
- Pus -- e.g., empyema.
- Chyle -- e.g., secondary to tumor.
- Foreign -- e.g., introduced via mal-positioned catheter.
No heme was present in the material suctioned by the chest tube.
No material was introduced via the chest tube.
The only reasonable remaining possibility is contrast in chyle entering the left pleural space via a lacerated thoracic duct.
- Contrast was introduced via the web space between the toes for lymphangiograpy, which then confirmed the persistent thoracic duct leak.

Final Note:

The thoracic duct was not initially injured by the stab wound to the left side of the neck.
The thoracic duct may have been injured by subsequent attempt at left subclavian central venous catheter placement.
The thoracic duct was subsequently ligated in the mediastinum.
The patient then developed coarse bilateral infiltrates which have been slow to improve.

Ref: Armstrong, P., et. al., Imaging of Diseases of the Chest, 2nd ed, Mosby, St. Louis, MO, 1995, pp. 681-685. excellent discussion!