PANCREATICO-PLEURAL FISTULA AND SUBSEQUENT FUNGAL EMPYEMA

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A rare pancreatitis complication is pancreatico-pleural fistula with empyema development being even more scarce. CASE PRESENTATION: A 48-year-old male with a history of alcoholic pancreatitis, subsequent mediastinitis with recurrent pleural effusions and pneumonia presented to the outpatient pulmonology office for persistent dyspnea. We ordered basic labs, showing significant leukocytosis and anemia, and a thoracentesis, removing 600 milliliters. Upon transferring to the hospital, further workup revealed elevated lipase and C-reactive protein. Pleural fluid studies indicated an amylase-rich exudative process. Chest-x ray showed bilateral pleural effusions and multilobar pneumonia. Computed Tomography (CT) Angiography of chest showed loculated moderate right and small left pleural effusion, multilobar pneumonia especially in lower lobes. CT of abdomen/pelvis showed acute pancreatitis and pancreatic cystic lesions in the head and uncinate process. We initiated broad coverage with Vancomycin, Cefepime, and Metronidazole. On day 3 of admission, a chest tube was placed and 6 doses of lytic therapy were administered. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was performed and confirmed pancreatico-pleural fistula (PPF). Thus, sphincterotomy was performed and a stent was placed; however, the pancreatic duct could not be cannulated. Video-Assisted Thoracoscopic Surgery was not indicated at this time. Pleural fluid cultures grew Candida Albicans and Micafungin was added. Upon receiving sensitivities, we discontinued the current regimen and started Fluconazole. Chest tube was removed on day 10 of admission. The patient was discharged home with instructions to continue Fluconazole for 6 weeks, weekly lab monitoring, repeat ERCP with pancreatic duct cannulation in 3 weeks, and repeat Chest x-ray in 2 months. DISCUSSION: PPF with pleural effusion is reported with an incidence of 0.4%. A pancreatic duct disruption causes persistent leakage of pancreatic secretions. Initially, a fluid collection forms, known as a pseudocyst. Eventually, the secretions can cause a spontaneous erosion into a neighboring organ or cavity, the pleural cavity in our case. Patients with PPF present similarly to pleural effusions, as they are recurrent and refractory to repeated thoracentesis. 1 In rare cases, an empyema can develop that can cause life-threatening sepsis. 2 Classical PPF patients are middle-aged men, chronic pancreatitis from alcoholism, dyspneic, no acute abdominal symptoms, left pleural effusions, pseudocyst on CT, and elevated pleural fluid amylase, lipase, and albumin. These were observed in our case, except bilateral pleural effusions, which has a 19% incidence compared to 74% for left sided. 1 CONCLUSIONS: As clinicians, we should consider the rare complications of PPF in the differential for patients with a history of pancreatitis presenting for dyspnea and sepsis. Reference #1: Machado, NO. Pancreaticopleural Fistula: Revisited. Diagnostic and Therapeutic Endoscopy. 2011;2012:1-5. Reference #2: Kim E, Ahn HY, Kim YD, Hoseok, Cho JS. Successful Diagnosis and Treatment of a Pancreaticopleural Fistula in a Patient Presenting with Unusual Empyema and Hemoptysis. Korean J Thorac Cardiovasc Surg. 2019;52(3):174-177. doi: 10.5090/kjtcs.2019.52.3.174. DISCLOSURES: No relevant relationships by Jacob Burch, source=Web Response No relevant relationships by James Choi, source=Web Response No relevant relationships by Rakesh Gami, source=Web Response No relevant relationships by Tyler Kemnic, source=Web Response No relevant relationships by Jason Liu Liu, source=Web Response No relevant relationships by Rohan Prasad, source=Web Response No relevant relationships by Fazal Raziq, source=Web Response No relevant relationships by Eric Smith, source=Web Response