Recurrent Spontaneous Chylopericardium Treated by Thoracic Duct Embolization

BACKGROUND: Spontaneous chylopericardium is a rare etiology of pericardial effusion and is a diagnosis of exclusion. CASE SUMMARY: A 45-year-old woman was incidentally found to have a large pericardial effusion on abdominal ultrasound performed for mildly elevated liver enzymes. Transthoracic echocardiography demonstrated early tamponade physiology, prompting urgent pericardiocentesis with drainage of chylous fluid. After early recurrence, intranodal magnetic resonance lymphangiography demonstrated reflux, and catheter-based lymphangiography confirmed a leak arising from the thoracic duct. She underwent percutaneous thoracic duct embolization with concomitant pericardial drainage, resulting in complete resolution without recurrence on follow-up. DISCUSSION: Magnetic resonance lymphangiography can identify occult sources of chylopericardium. Percutaneous thoracic duct embolization provides a minimally invasive alternative to surgical ligation for definitive treatment of thoracic duct leaks. TAKE-HOME MESSAGES: Recurrent spontaneous chylopericardium should prompt evaluation for thoracic duct pathology. Potentially curative thoracic duct embolization should be considered early.