Disorders of the Pleura |

A Curious Case of a Reaccumulating Black Colored Pleural Effusion! FREE TO VIEW

Swagatam Mookherjee, MD; Nathan Minkoff, BS; Vishal Shah, MBBS; Brian Changlai, MD
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SUNY Upstate Medical University, Syracuse, NY

Chest. 2014;146(4_MeetingAbstracts):482A. doi:10.1378/chest.1992338
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SESSION TITLE: Pleural Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: A persistent black colored pleural effusion is an unusual sight to come across with unusual etiologies, one of which being a pancreaticopleural fistula! Diagnosis of such fistula should be entertained when faced with a reaccumulating, black colored, pleural effusion.

CASE PRESENTATION: A 37 year old female with unknown PMH presented to the hospital with progressive dyspnea, right sided chest pain and tenderness, palpitations and orthopnea for the past 2 weeks. On presentation, CXR showed a right sided pleural effusion. A diagnostic and therapeutic thoracentesis was performed which revealed a black colored effusion! Analysis of the pleural fluid via Light's criteria revealed an exudative effusion . Anticipating a parapneumonic effusion, gram stain and culture were drawn, but returned unremarkable. Following CXR was evident for reaccumulation. CT surgery was consulted for chest tube insertion. Follow up CXRs were significant for persistent right sided pleural effusion despite adequate drainage. Outside hospital records were obtained, revealing that the patient had a history of chronic pancreatitis secondary to alcohol abuse, complicated with pancreatic pseudocysts requiring a lengthy hospital course. Patient was questioned again about her social history. She admitted to drinking socially despite her chronic pancreatitis. In light of possible pancreatic etiology, pleural amylase was drawn, revealing an astounding value of 26,673 IU/L! Further investigation via CT and MRCP revealed a well defined walled off peripherally enhancing tubular structure extending from pancreatic body cranially to the inferior mediastinum and right inferiomedial pleural space suggestive of a fistulous connection. Diagnostic and therapeutic ERCP was performed which confirmed presence of the fistula. The main pancreatic duct was stented, allowing for resolution of fistula by facilitating flow of pancreatic enzymes to the duodenum, aided by enzyme inhibiting action of octreotide. This intervention allowed for resolution of the chronic pleural effusion and resolution of the patient's symtoms.

DISCUSSION: A recurring black colored pleural effusion should remind one to entertain the possible diagnosis of pancreaticopleural fistula. Key to diagnosis includes procuring a pertinent history, which typically includes a history of chronic pancreatitis. Subsequently, pleural amylase should be drawn, 1000+ is indicative, 50,000 is diagnostic. Fistulas mostly result in left sided pleural effusions due to proximity of pancreas, but may occur on the right as in this case. CT, MRCP, ERCP confirm the diagnosis.

CONCLUSIONS: A reaccumulating, black colored pleural effusion in either lung can be caused by a pancreaticopleural fistula. A high pleural amylase and history of chronic pancreatitis are indicative. Diagnosis can be confirmed by CT, MRCP, and ERCP.

Reference #1: Black pleural effusion The American Journal of Medicine (2013) 126, 641.e1-641.e6

DISCLOSURE: The following authors have nothing to disclose: Swagatam Mookherjee, Nathan Minkoff, Vishal Shah, Brian Changlai

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