Our patient is a 41-year-old woman with a history of chronic pancreatitis for 21 years due to EtOH abuse, dyspepsia, chronic hepatitis C, and hypertension. Her chronic pancreatitis and dyspepsia were managed with pancrelipase and famotidine. Of note, the patient had a 30-pack-year smoking history and denied current alcohol use. Upon arrival at the emergency department, our patient reported a 3-day history of dyspnea on exertion and orthopnea. She endorsed nonradiating right-sided chest pain and denied hemoptysis, productive cough, chest trauma, or vomiting. The patient presented with tachycardia to 100 s and tachypnea to 30 s and with a pulse oximetry reading of 95%. The patient was trialed on BiPAP for improvement of acute hypoxic respiratory failure and ultimately required placement of a high-flow nasal cannula. She was then weaned to room air within less than 24 h after admission.
The physical exam was remarkable for diffuse crackles in lung fields bilaterally, decreased breath sounds at the lung bases bilaterally, and tachycardia. Abdominal exam was benign. Chest X-ray demonstrated large left pleural effusion and moderate to large right pleural effusion, with predominantly perihilar alveolar opacities (Fig. 1). Therapeutic thoracentesis on the left side revealed 1.550 L of markedly bloody, serosanguinous pleural fluid with the following values: amylase 630 U/L, lipase 805 U/L, LDH 681 U/L, adenosine deaminase 29.3 U/L, cholesterol 58 mg/dL, glucose 114 mg/dL, protein 5.0 g/dL, and triglycerides 25 mg/dL. ANA screen was negative. Cytology demonstrated histiocytes and benign mesothelial cells, with no malignant cells identified.
A chest CT was done after the left thoracentesis that demonstrated the expansion of the moderate to large right pleural effusion and new development of left hydropneumothorax, along with a large posteroinferior mediastinal fluid/mass that could represent pleural and pericardial or pancreatic fluid (Fig. 2). CT of the abdomen was notable for enlargement of the pancreatic duct and a stable pancreatic pseudocyst. Given the positive adenosine deaminase in the pleural fluid, a QuantiFERON Gold was ordered and returned positive. Active TB was subsequently ruled out with negative AFB culture and MTB PCR. A pigtail catheter was placed on the left side for definitive management of hydropneumothorax with a collapsed lung. Subsequent chest X-ray demonstrated slightly worsened hydropneumothorax, concerning for a persistent trapped lung with ex vacuo findings (Fig. 3). A subsequent chest CT demonstrated large left-sided pneumothorax ex vacuo with small persistent right-sided pleural effusion. Thoracic surgery was consulted, and a left lung video-assisted thoracoscopic surgery decortication for the treatment of the trapped lung was performed. Several pleural biopsies were taken to evaluate for malignancy, TB, or fungal etiology, which revealed an abscess with fibrosis and pleura with inflammation and focal mesothelial hyperplasia. Due to recurrent expansion of right-sided exudative loculated effusion, a right chest tube was placed and a few days later, a left chest tube was placed for reaccumulating intrapleural fluid.
Gastroenterology was consulted for ERCP with endoscopic ultrasound to further evaluate for a pancreatic source of elevated amylase in the pleural fluid. Endoscopic ultrasound was negative for masses, lymphadenopathy, or other signs of malignancy. ERCP demonstrated a dilated pancreatic duct and leakage at the tail or upstream body, likely representing a fistula to the pleura. Sphincterotomy was performed, and a plastic stent was placed to promote flow of pancreatic secretions internally, thus decreasing flow through the fistula and facilitating closure of the fistula. Bilateral pleural effusions subsequently improved and did not reaccumulate, and the chest tubes were removed.