178 JE Kim, et al. • Pleurodesis with OK-432 in neonates, Matsukuma et al.12) lately reported the successful use of OK­432 for the treatment of prolonged congenital chylothorax in 2 newborn infants who failed to respond to conservative medical therapy, including octreotide infusion. Here we report a first trial of intrapleural instillation of OK­432 in two preterm infants with persistent congenital chylothorax in Korea. Case reports 1. Case 1 A male preterm infant (gestation 33 weeks, birth weight 2,720 g) was born by C­section with hydrops fetalis. A fetal sonogram showed generalized edema, bilateral pleural effusion (right, 2.3 cm; left, 1.3 cm) and pericardial effusion at 32 weeks gestation. No specific antenatal management was performed, except for one cycle of antenatal dexamethasone. APGAR scores were 3 at 1 minute and 4 at 5 minutes. The infant showed respiratory difficulty and required immediate mechanical ventilation. Congenital chylothorax was confirmed by analysis of pleural fluid: elevated triglyceride (202 mg/ dL) after premature milk feeding, and predominant lymphocyte count (>90%). Other tests were all negative. The infant was initially treated with chest tube drainage and total parenteral nutrition combined with balanced replacement of fluid and albumin losses. Left pleural drainage had resolved after two week. However, amounts of right pleural fluid remained high, fluctuating between 30 to 320 mL/day until postnatal day 25. Octreotide infusion started on postnatal day 26, and lasted for two weeks. Initial dose was 0.5 gµ/ kg/hr and was increased up to a maximum dose of 10 µg/kg/hr. However, no significant decrease in right pleural drainage was noted and reaccumulation of left pleural effusion showed up. We decided to use intrapleural instillation of OK­432 after obtaining informed consent. 0.1 Klinische Einheit (KE) OK­432 (at a concentration of 1 KE in 10 mL normal saline) was injected into the left pleural cavity on postnatal day 46 and into the right pleural cavity on postnatal day 48. The amount of pleural fluid drainage dramatically decreased right after OK­432 injection, and did not reaccumulate, resulting in the chest tube finally being removed 14 days after the OK­432 instillation (Fig. 1). No immediate side effects were detected related to OK­432 instillation. Unfortunately, the infant was already suffering from significant oliguria, worsening edema and recurrent hypotension. He died from renal failure, shock, and candida peritonitis related to peritoneal dialysis on postnatal day 72, even though chylothorax had resolved completely after OK­432 pleurodesis. 2. Case 2 A female preterm infant (case 2, gestation 29 weeks and 6 days weeks, birth weight 1,790 g) was born by C­section with bilateral pleural effusion, diagnosed at 27 weeks of gestation. APGAR score was 2 at 1 minute, 6 at 5 minutes. The infant had been treated with thoracentesis and intrapleural instillation of OK­432 during the fetal period at 28 weeks and 4 days of gestation, but showed recurrence of pleural effusion after seven days of instillation of OK­432 and progressed into hydrops fetalis at 29 weeks and 6 days of gestation. Analysis of fetal pleural fluid demonstrated the presence of more than 99% lymphocytes suggesting congenital chylothorax, while culture of the fluid was sterile. Fetal karyotype and viral studies were all negative. Left pleural effusion was continued at an average rate of 80 mL/day during the first two week, and it was then decreased ) L m ( d i u l f l a r u e l P Postnatal day Fig. 1. Changes in pleural drainage after OK-432 (picibanil) instillation in case 1. Lt, left; Rt, right.