Fever persisted, and 3 days later a repeat chest roentgenogram showed a new right pleural effusion with an air-fluid level (Fig 1
). It was thought that a parapneumonic effusion and an accompanying self-limited bronchopleural fistula had developed in the patient. The pleural fluid protein level was 0.7 g/dL (serum protein level, 4.5 g/dL; ratio, 0.2), and the LDH level was 65 U/L (serum LDH level, 106 U/L; ratio, 0.6). The pleural fluid glucose level, measured by spectrophotometry, was 843 mg/dL. The simultaneous serum glucose level was 115 mg/dL (ratio, 7.3). Measurements of the pleural fluid amylase level and pH were not obtained. Pleural fluid analysis also showed numerous WBCs and many budding yeast cells. Gram stain and culture findings showed the presence of Lactobacillus acidophilus and Candida albicans. Blood cultures grew L acidophilus. On further questioning by the pulmonary service, the patient stated that he had ingested a cola 2 h before thoracentesis. A repeat physical examination revealed no subcutaneous crepitus. Based on the clinical history of esophageal carcinoma, elevated pleural fluid glucose levels, the recent ingestion of a cola, and a new air-fluid level, esophageal perforation was suspected. A CT scan of the thorax confirmed distal esophageal perforation with fistula formation involving the right pleural space (Fig 2
). In order to confirm the oral source of organisms found in the pleural fluid, a mouth swab was obtained for a culture of L acidophilus and C albicans, which grew C albicans only. The patient refused surgical intervention and died several days later.