INTRODUCTION:Pleuropancreatic fistulas complicate <1% of pseudocysts. These are usually associated with chronic pancreatitis secondary to a history of alcoholism in 90% of cases. The development of the fistula is usually heralded by the development of a ‘left’ sided pleural effusion characteristically with an elevated fluid amylase. Management with total parenteral nutrition (TPN) and octreotide, aiming to decrease the pancreatic exocrine function, usually heals the tract. However, if the picture is complicated with a coexistent empyema the management of the pseudocyst becomes more challenging.
CASE PRESENTATION:A 69 year old African American woman was admitted for the evaluation of worsening shortness of breath (SOB) for 1 week. She was admitted 3 months prior for SOB and also for chronic abdominal pain associated with diarrhea. The patient neither smoked nor drank alcohol. A computed tomography (CT) of the abdomen revealed bilateral pleural effusions, an atrophic pancreas and an abnormal soft tissue density extending superiorly to the level of the left atrium, surrounding the distal thoracic aorta and extending into the retroperitoneum. A thoracentesis revealed an exudative fluid with a lactate dehydrogenase (LDH) of 499, protein 2.4, glucose 71 and a white blood cell count (WBC) 480mm3, neutrophilic predominant. Culture and cytology were negative. The patient was discharged after her SOB improved to be worked up as an outpatient.This admission the SOB was much worse and was associated with fevers. A CT confirmed a massive ‘right’ sided effusion with interval improvement of the periaortic soft tissue density. On repeat tap, the pleural fluid showed an LDH of 3030, protein 2.2, glucose less than 5, pH of 6.80 and a WBC 17,100mm3. The amylase level was 4476 U/L. Serum amylase was 53 U/L. A follow up MRCP was then performed which defined a fluid collection, 3.2 × 2.6 cm, in the uncinate process dissecting to the right of the aorta in a paraesophageal location and ending by communicating with the right medial basal pleura. The pleural culture grew Streptococcus pneumonae, susceptible to penicillin. CT guided biopsy of the pancreatic pseudocyst yielded purulent material which ‘also’ grew Streptococcus pneumonae. In light of the pancreatopleural fistula, the empyema and the concurrent infection of the pseudocyst, decision was made to start TPN and antibiotics, place a chest tube and prepare for a right sided pleural decortication and subsequent surgical obliteration of the fistulous tract. The patient, however clinically deteriorated with the development a new left sided pneumonia and florid septic shock. The patient expired within 24 hours of reaching the medical intensive care unit despite maximal support.
DISCUSSIONS:Superinfection of a pancreatic pseudocyst is associated with a significantly increased morbidity and mortality. The predominant culprits include aerobic gram negative organisms (E. coli, Klebsiella, Proteus) and occasionally gram positive organisms (Staphyloccocus aureus, Enterococcus feacalis). ‘Pneumococcus’ pseudocyst infection is extremely rare and has scarcely been reported in the literature. The route of infection has never been clearly defined. Alcoholism, however has almost always been associated, thought to result in ineffective chemokine and macrophage activity and predisposing to bacteremia from a possible aspiration event. Here the superinfection was most certainly a result of the transmission of the Pneumococcus from the empyema via the fistulous tract to the pancreatic pseudocyst, a phenomenon that has never been described before.
CONCLUSION:Superimposed infection of a pseudocyst connected to a pleural space via a fistulous tract can occur via translocation of pneumonia causing organisms. Management also becomes more challenging calling for not only a possible stenting of the pancreatic duct but also a decortication procedure with lung resection.
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