UNEXPECTED EFFUSION: BILOTHORAX IN PATIENT WITH METASTATIC BREAST CANCER

Abstract

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilothorax is a rare cause of pleural effusion. It is thought to be caused by translocation of bilious fluid through a diaphragmatic defect, whether passive, congenital or iatrogenic [1,2]. It is often described as a rapidly-accumulating, right-sided pleural effusion occurring after instrumentation near to or on the biliary tree. Patients are at high risk of developing empyema and can present with signs of infection. We describe a case of a slowly-accumulating right-sided bilothorax in a patient without signs of infection. CASE PRESENTATION: A 39 y/o lady with history of triple-negative breast cancer, metastasized to the brain and spine, was referred to our clinic for dyspnea on exertion for 1 month. She had been treated with multiple lines of chemotherapy & proton beam radiation to her metastases. A staging PET/CT scan 3 months prior revealed a liver lesion that was suspicious for metastases. A CT-guided percutaneous liver biopsy was recommended. An abdominal scan incidentally caught segmental pulmonary emboli (PE), for which a chest CT was performed. Due to a post-procedural complication of hepatic sub-capsular hematoma, the patient was not anti-coagulated & had IVC filter placement instead. Her chest imaging at this time was revealing of minimal, trace bilateral effusions. She presented 1 month later for staging scans. Chest imaging at this time was significant for a trace right-sided pleural effusion. The patient did not have any respiratory symptoms. When she was seen by her oncologist for follow-up one month thereafter, she reported feeling dyspnea on exertion. At this point, a CT chest confirmed a small-to-moderate right pleural effusion. She had no fevers, cough, or constitutional symptoms except chronic fatigue and weakness which preceded her dyspnea. In our clinic, we appreciated a moderate-sized right pleural effusion on ultrasound. Given the insidious nature of her dyspnea, we postulated that her effusion was likely malignant. We performed thoracentesis for both diagnostic and therapeutic purposes. A total of 1.1L of dark green fluid was drained. Fluid studies returned with a pleural fluid to serum bilirubin ratio greater than one, confirming bilothorax. Cytology of the effusion was negative for cancer cells. Repeated chest imaging at 1 and 2 months post-thoracentesis did not reveal re-accumulation of pleural fluid, and patient’s dyspnea did not return. DISCUSSION: We describe a case of a slowly accumulating bilothorax after percutaneous CT-guided liver biopsy. Fortunately, our patient did not develop an empyema from this effusion. CONCLUSIONS: A high suspicion for bilothorax should be maintained when patients develop a novel pleural effusion within the days to months following an abdominal procedure in close proximity to the biliary tree. Prompt diagnosis and drainage lends to both symptomatic relief & prevention of further complications of infection in the pleural space. Reference #1: Jenkinson MRJ, Campbell W, Taylor MA. Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl. 2013;95(7):e12-e13. doi:10.1308/003588413X13629960047678 Reference #2: Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl. 2010;92(5):W53-W54. doi:10.1308/147870810X12699662980637 DISCLOSURES: No relevant relationships by Saamia Hossain, source=Web Response No relevant relationships by Robert Lee, source=Web Response