Recurrent Pleural Effusion Complicating Spontaneous Rupture of Pancreatic Pseudocyst

Abstract

Introduction: Pancreatic pseudocysts are commonly seen complicating acute pancreatitis with a reported prevalence of 6-18.5 % and higher rates in cases of chronic pancreatitis 20 to 40%. We present interesting case of spontaneous rupture of pseudocyst into the pleural cavity presented with recurrent pleural effusion. Case Description: A 74-year-old male patient with medical history of necrotizing pancreatitis complicated with pancreatic pseudocyst admitted with abdominal pain and dyspnea. Patient was diagnosed with acute pancreatitis 1 month ago of unknown cause then re-admitted 4 weeks later with necrotizing pancreatitis managed conservatively. CXR then showed left side pleural effusion. Thoracentesis was done with removal of 450 cc exudative fluid with total protein of more than 3 g/dl and negative cytology and culture results. Initial vitals were BP 84/52, HR 106 bpm, temperature 97.8 F, respirations 18 bpm and oxygen saturation 97% on 2-liter oxygen. He had abdominal distention with right upper quadrant tenderness and bilateral lower extremity edema. Labs showed ammonia level of 38 ug/dl, BUN 33 mg/dl, Cr. 1.67micromol/L, albumin 2.4 g/L, lipase 172 U/L, Alk phos 187 IU/L, wbc 19.3, and hgb 10.5 g/dl. CXR showed left sided pleural effusion. CT abdomen revealed worsening of the peripancreatic fluid collection with extension into the left upper quadrant, retroperitoneum, compression of the stomach and upper abdominal venous structures. Patient had free fluid in the colonic gutters, around the liver and spleen and in the pelvis and loculated pleural fluid at the left lung base. Fluid and antibiotics were started and CT guided percutaneous drainage of pancreatic pseduocyst was done. Thoracentesis was repeated with the removal of 450cc transduative fluid with elevated amylase level 223, normal cholesterol 34, triglyceride 18, total protein < 3 and albumin 1.5. Patient had normal IgG4 and CA 19-9 level. Patient expired few days later. Discussion: Pleural effusion complicating acute pancreatitis is usually small and left sided, recurrent, and refractory to drainage. It normally has amylase level of 1000 U/L and protein concentration above 3 g/dl. Pancreaticopleural fistula (PPF) have been reported in 2.3 to 4.5 % patients with pancreatic pseudocyst. Diagnosis need CT scan, ultrasound or ERCP. Management includes drainage of effusion with chest tube and if that fails, then percutaneous or endoscopic drainage of the pseudocyst should be considered.2914 Figure 1. abdomen showed fluid collection around the pancreas, retro peritoneum, barely visible normal pancreatic tissue and left sided pleural effusion [Arrows]