A 74 year old woman presented with dyspnoea on exertion. She had been hypertensive for 25 years and underwent triple coronary by-pass grafting (CABG) with saphenous vein and left internal mammary artery through a median sternotomy 14 days previously. She was on diuretics and digitalis. Physical examination revealed a sternotomy scar and decreased breath sounds at the left lung base. Vital signs and other systems were normal. Chest radiography and thoracic computed tomography are shown in figs 1 and 2. She had a high white blood cell count 15 × 10⁹/l, neutrophilia (78%), lymphopenia (10.6%), a high erythrocyte sedimentation rate (68 mm/hour) and a low serum albumin level (33 g/l). Diagnostic pleural tap yielded turbid milky fluid consisting 0.045 g/l protein, 226 IU lactic dehydrogenase, 11.6 mmol/l triglycerides, and 3.7 mmol/l cholesterol. Lymphoscintigraphy showed lymphatic leakage to the mediastinum.

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Figure 1

 Chest radiograph.

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Figure 2

 Computed tomogram.

QUESTIONS

1. Describe the chest radiograph and thoracic computed tomography findings.

2. What is the most likely diagnosis?

3. What is the most likely mechanism of the disorder?

4. What do you recommend for the treatment?