Imaging |

Mediastinal Mass With Accompanying Pleural Effusion- An Uncommon Presentation of Pancreatic Pseudocyst FREE TO VIEW

Chidozie Agu, MD; Frances Marie Schmidt, MD; Lamont Brown, MD; Rawshan Ali Basunia, MD; Bikash Bhattarai, MD; Vikram Oke, MD; Danilo Enriquez, MD; Joseph Quist, MD
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Interfaith Medical Center, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):501A. doi:10.1378/chest.2278506
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SESSION TITLE: Imaging Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Mediastinal pancreatic pseudocysts are very uncommon as most pseudocysts typically occur in the peripancreatic area. In very rare instances they may be complicated by the formation a pancreatic-pleural fistula resulting in persistent or recurrent pancreatic pleural effusions.

CASE PRESENTATION: A 40 year old man with a history of chronic alcohol abuse and chronic pancreatitis, presented with complaints of severe epigastric and right sided chest pain which had been present for the past few months but became unbearable over the past few days, mild dyspnea at rest, loss of appetite and weight loss of about 20 pounds in the past two months. The patient appeared cachectic, mildly tachypneic and tachycardic on examination. Labs on admission were normal except for mildly elevated amylase (326 U/L) and lipase (116 U/L) levels. Chest X-ray revealed a moderate right pleural effusion. Pleural tap revealed an exudative fluid with lymphocytic predominance and amylase of 2175 U/L, suggestive of a pancreatic pleural effusion. A chest/abdomen CT showed a large right loculated pleural effusion contiguous with a long pancreatic pseudocyst (9 x 4.9 x 5.2 cm) extending from the tail of the pancreas into the posterior mediastinum. A CT guided drainage of the loculated pleural effusion was performed, with aspiration of fluid with very high amylase content and a pig-tail catether was left in place. There was significant improvement of sypmtoms post-drainage and a follow-up CT showed interval reduction in size of the pseudocyst.

DISCUSSION: Pancreaticopleural fistulas are very rare and have been observed in only 2-5% of patients presenting with pancreatic pseudocyst. It typically presents with chest pain, abdominal pain, dyspnea and or dysphagia. Recurrent or persistent pleural effusion is a common finding. The finding of an elevated amylase level on analysis of the cystic content or accompanying pleural effusion is required for definitive diagnosis. Treament modalities include conservative measures (pancreatic rest, serial thoracocentesis or octreotide); endoscopic therapy (ERCP and stenting) and surgery in case of failure of the aforementioned therapies.

CONCLUSIONS: Pancreaticopleural fistulas should be suspected in patients with acute or chronic pancreatitis especially those who present with pseudocyts and recurrent pleural effusions.

Reference #1: Nagaraja Moorthy, et al. Pancreaticopleural fistula and mediastinal pseudocyst: An unusual presentation of acute pancreatitis.Ann Thorac Med. 2007 Jul-Sep; 2(3): 122-123.

DISCLOSURE: The following authors have nothing to disclose: Chidozie Agu, Frances Marie Schmidt, Lamont Brown, Rawshan Ali Basunia, Bikash Bhattarai, Vikram Oke, Danilo Enriquez, Joseph Quist

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