SESSION TITLE: Pleural Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: A black pleural effusion is extremely rare, and only 8 cases have been reported to date. The causes can be divided into infectious, malignant and hemorrhagic.1
CASE PRESENTATION: Our patient is a 37 year old female, former alcoholic, who presented with 2 weeks of coryza followed by 5 days of dyspnea, orthopnea and pleuritic chest pain. She was found to have a right sided pleural effusion. 1 litre of pleural fluid was drained. It was black in color, transudative on analysis but with very high amylase level of 23,000 U/l. Serum amylase was normal. Fluid cytology was benign. CT scan abdomen showed a 2 cm fluid collection superior to the body of pancreas with heterogenous thickening of pancreas. No definite fistula was seen. Esophagogram was normal. MRCP only showed prominent pancreatic duct. Repeat amylase level in pleural fluid was normal. She was treated for presumptive parapneumonic effusion. Patient’s pleural effusion and symptoms recurred and a chest tube had to be placed. She also underwent decortication which was complicated by hemothorax. Amylase level in fluid became high again.Thus a repeat CT abdomen was done which showed well-defined walled off tubular structure extending from the pancreatic body cranially to the inferior mediastinum and right inferomedial pleural space suggestive of fistulous connection. Patient finally underwent ERCP guided pancreatic duct stent placement. This led to the resolution of pleural effusion.
DISCUSSION: Rupture of a pancreatic pseudocyst is one of the hemorrhagic causes of a black pleural effusion.1Pancreaticopleural fistulas (PPF) develop from leakage of pancreatic exocrine secretions cephalad through openings in the diaphragm in chronic pancreatitis.2 It is different from acute pancreatitis as it is recurrent and without acute pancreatic inflammation. Only 20% of patients complained of abdominal pain.2 A fluid amylase level greater than five times the serum amylase is highly characteristic of PPFs.
CONCLUSIONS: PPF should be considered as a cause of black, massive, recurrent pleural effusion in an alcoholic patient even without abdominal symptoms. The predominance of thoracic symptoms often causes initial efforts to be directed toward finding a thoracic pathology, thus resulting in a delay in diagnosis and increase in morbidity.
Reference #1: Saraya T, Light RW,Hajime Takizawa H, Goto H.Black pleural effusion.Am J Med. 2013 Jul
Reference #2: Clifton Ming Tay, Stephen King Yong Chang. Diagnosis and management of pancreaticopleural fistula. Singapore Med J 2013.54(4): 190-194
DISCLOSURE: The following authors have nothing to disclose: Dilpreet Kaur, Gaganjot Singh, Emerald Banas, Dana Savici
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