PMC4921165_01
Chest radiograph demonstrates a right-sided pleural effusion, a right clavicle lytic lesion (white arrow). and several old left rib fractures (black arrows).
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A chest radiograph revealed a right-sided pleural effusion, a right clavicle lytic lesion, and several old left rib fractures (Fig. 1).
Left-lower-extremity radiographs show multiple focal expansile lytic lesions involving the cortex of the tibia and fibula, with a pathologic fracture through the middle tibia (white arrows).
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Left-lower-extremity radiographs revealed multiple focal expansile lytic lesions involving the cortex of the tibia and fibula, with a pathologic fracture through the middle tibia (Fig. 2).
Contrast-enhanced CT of the chest, abdomen, and pelvis. Sagittal imaging (A and B) demonstrates multiple lytic lesions involving various vertebral bodies, ribs, and pelvis (black arrows). Coronal imaging (C) shows innumerable hypodense splenic lesions representing lymphangiomatosis and an extensive right-sided pleural effusion (white arrow).
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In addition, a large right-sided pleural effusion and multiple hypodense splenic lesions compatible with lymphangiomatosis were also present (Fig. 3).
Coronal T2-weighted Fast Inversion Recovery image shows a large cystic mass extending from the right anterior thorax to the axilla (black arrow), and a cystic lesion in the proximal right humerus (white arrow). This right chest mass was surgically excised four years before presentation, and the histopathology revealed thin-walled, dilated lymphatic vessels consistent with a lymphangioma.
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A review of the patient's past medical history revealed the surgical removal of a large cystic mass from the right anterior chest wall four years before (Fig. 4).
Nuclear medicine lymphoscintigraphy study performed with Tc-99m filtered sulfur colloid injected into the interdigital webs of the patient's right hand. Sequential imaging obtained at 2 minutes/frame. Normal lymphatic drainage was seen within the right upper chest. Faint early activity is seen within the right chest tube (A). On delayed imaging (B), significant activity is seen within the right chest tube (arrow) and drainage container. This study confirmed injury to the lymphatic drainage system leading to recurrent chylothorax.
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Given her history, a nuclear medicine lymphoscintigraphy study was performed and demonstrated injury to the lymphatic drainage system leading to chylothorax (Fig. 5).
Coronal Short Tau Inversion Recovery (STIR) image (A) shows multiple hyperintense lesions in the right humerus (white arrow). Also seen is a remnant or recurrence of the previously excised lymphangioma (black arrow). Coronal T1-weighted imaging (B) shows multiple bilateral hypointense humerus lesions (white arrowheads).
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An MRI of the chest was then obtained for further evaluation of the patient's chest wall and the right humeral lesions in anticipation of biopsy (Fig. 6).