Black pleural effusion

Unveiling Complexity: Black Pleural Effusion Due to a Pancreaticopleural Fistula

Black pleural effusions (BPEs) are an exceedingly rare class of exudative effusions of unexplored causality. Their characteristic pitch-black coloring and striking first appearance upon thoracocentesis make them a bewildering occurrence even for seasoned physicians. Forming a free-from-error diagnostic work-up can be arduous and largely depends on thorough history-taking, deliberate imaging studies, and the correct biochemical profile. The upcoming article aims to raise awareness of this pathology by presenting our experience with a BPE after an episode of acute-on-chronic (ACP) pancreatitis and the confounding route to achieving the correct diagnosis and forming the precise therapeutic approach to this scenario. Keeping in mind that this is not a common clinical case, we strive to dispel some misconceptions and thus avoid any subsequent complications and delays in diagnosis when treating this type of effusions and their underlying pathology.

Outcomes for Malignant Pleural Effusions Because of Melanoma Treated With Indwelling Pleural Catheters

BACKGROUND

Indwelling pleural catheters (IPCs) reduce dyspnea and improve quality of life in patients with malignant pleural effusions (MPEs). Data on outcomes of MPEs secondary to metastatic melanoma managed with IPCs are scarce. We aimed to evaluate outcomes of patients receiving IPCs for MPEs secondary to melanoma compared with other malignancies.

METHODS

We identified patients from our prospectively collected database of all patients who had an IPC insertion for MPEs at our tertiary care center for melanoma between May 2006 and November 2018 and for nonmelanoma between May 2006 and June 2013. Chart reviews were conducted to obtain patient demographics, catheter complications, time of IPC removal or death, x-ray imaging, and pleural fluid characteristics.

RESULTS

We identified 27 MPEs because of melanoma and 1114 because of nonmelanoma malignancies treated with IPC. The most frequent complication was pleural fluid loculation requiring fibrinolytics which was significantly higher in the melanoma (14.8%) compared with the nonmelanoma group (3.8%; P =0.02). Cumulative incidence functions for catheter removal ( P =0.8) or death with catheter in situ ( P =0.3) were not significant between melanoma and nonmelanoma groups in competing risk analysis. Baseline radiographic pleural effusion scores were similar, but became significantly higher (increased pleural opacity) in the melanoma group at time points following IPC insertion ( P <0.05).

CONCLUSION

MPEs because of melanoma had a higher rate of loculations requiring fibrinolytics and less radiographic improvement after IPC insertion suggesting this patient subgroup has a more complicated pleural space which may be less responsive to drainage.

Three cases of black pleural effusion

Black pleural effusions (BPE) are rare, exudative pleural effusions that produce a black fluid on thoracentesis. While the name and definition of this pathology is undeniably simple, the etiologies, outcomes, and treatments for BPE are incredibly complex. Currently, BPE is not well-demonstrated in the literature. This case series reports three patients with different etiologies, past medical histories, presenting symptoms, treatments, and outcomes. BPE caused by pancreatic-pleural fistula and opportunistic infections are demonstrated in this case series. This report shows that early identification and treatment of the underlying cause of BPE is critical to the recovery of the patients.

Black Pleural Effusion as a Complication of Acute Pancreatitis

Transient and reactive pleural effusion is a known consequence of acute pancreatitis. Usually, the pleural effusion is unilateral, transudate, straw-colored, and self-resolving. We report a rare case of massive left-sided black pleural effusion as a complication of acute pancreatitis with the background of chronic pancreatitis being secondary to alcohol abuse. The pleural effusion resulted in hypoxic respiratory failure. However, the patient had significant improvement after drainage of the pleural effusion and the appropriate management of sepsis with broad-spectrum antibiotics. The patient had a significant improvement and recovery with conservative management without the need for endoscopic therapy or surgical intervention.

Characteristics of pleural effusion with a high adenosine deaminase level: a case-control study

Background

Increased pleural fluid adenosine deaminase (ADA) is useful for diagnosing tuberculous pleurisy (TB), but high ADA levels are associated with other diseases. In this study, we compare various disease characteristics in patients with high-ADA pleural effusion.

Methods

We retrospectively collected data for 456 patients with pleural fluid ADA levels of ≥ 40 U/L from January 2012 to October 2021. Cases were classified as TB (n = 203), pleural infection (n = 112), malignant pleural effusion (n = 63), nontuberculous mycobacteria (n = 22), malignant lymphoma (ML) (n = 18), autoimmune diseases (n = 11), and other diseases (n = 27), and data were compared among those diseases. Predictive factors were identified by comparing data for a target disease to those for all other diseases. A diagnostic flowchart for TB was developed based on those factors.

Results

The most frequent disease was TB, though 60.0% of patients were diagnosed with other diseases. Median ADA levels in patients with TB were 83.1 U/L (interquartile range [IQR] 67.2–104.1), higher than those of patients with pleural infection (median 60.9 [IQR 45.3–108.0], p = 0.004), malignant pleural effusion (median 54.1 [IQR 44.8–66.7], p < 0.001), or autoimmune diseases (median 48.5 [IQR 45.9–58.2], p = 0.008), with no significant difference from NTM (p = 1.000) or ML (p = 1.000). Pleural fluid lactate dehydrogenase (LDH) levels of < 825 IU/L were beneficial for the diagnosis of TB. Neutrophil predominance or cell degeneration, white blood cell count of ≥ 9200/µL or C-reactive protein levels of ≥ 12 mg/dL helped in diagnosing pleural infection. Pleural fluid amylase levels of ≥ 75 U/L and a pleural fluid ADA/total protein (TP) ratio of < 14 helped in diagnosing malignant pleural effusion. High serum LDH and high serum/pleural fluid eosinophils helped in diagnosing ML and autoimmune diseases, respectively. The flowchart was comprised of the following three factors: pleural fluid LDH < 825 IU/L, pleural fluid ADA/TP of < 14, and neutrophil predominance or cell degeneration, which were decided by a decision tree. The diagnostic accuracy rate, sensitivity, and specificity for the diagnosis of TB were 80.9%, 78.8%, and 82.6%, respectively.

Conclusion

Cases involving high pleural fluid ADA levels should be investigated using several factors to distinguish TB from other diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02150-4.

Black pleural effusion caused by a pancreaticopleural fistula associated with autoimmune pancreatitis: A case report

RATIONALE

Black pleural effusion is a rare medical condition and a diagnostic marker. Pancreaticopleural fistula is one of the causes of black pleural effusion. Thus far, black pleural effusions caused by pancreaticopleural fistulae have mostly been reported in patients with alcohol-induced chronic pancreatitis. In this report, we present a case of black pleural effusion caused by a pancreaticopleural fistula associated with autoimmune pancreatitis.

PATIENT CONCERNS AND DIAGNOSIS

A 59-year-old female without a history of alcohol drinking presented to our hospital with a chief complaint of dyspnea, as well as chest and back discomfort. She had left pleural effusion, and thoracentesis showed black pleural effusion. Computed tomography revealed the presence of encapsulated fluid from the pancreatic tail to the left pleural cavity, which was diagnosed as a pancreaticopleural fistula. It also showed diffuse pancreatic swelling. Serum testing showed a high IgG4 level (363 mg/dL). These findings led to the diagnosis of autoimmune pancreatitis.

INTERVENTIONS AND OUTCOME

The patient underwent endoscopic pancreatic sphincterotomy and pancreatic duct stent placement and received treatment with steroids. After treatment, there was no further accumulation of pleural effusion observed.

CONCLUSION

This is the first report of black pleural effusion due to a pancreaticopleural fistula associated with autoimmune pancreatitis. The characteristic appearance of black pleural effusion may assist diagnosis. We report this case to emphasize that autoimmune pancreatitis can be a cause of black pleural effusion.

Etiology, pathological characteristics, and clinical management of black pleural effusion: A systematic review

BACKGROUND

Pleural effusion is characterized by excessive fluid collection in the pleural cavity. Black pleural effusion (BPE) is a rare entity with only limited scientific data. We aimed to review the current literature on black pleural effusion to characterize demographics, etiology, clinical presentation, pathological findings, available treatment strategies, and prognosis of this rare condition.

METHODS

We performed a systematic review of case reports and series and synthesized data on demographics, manifestations, management, and outcomes of patients with BPE. We searched Cochrane Library, PubMed, SCOPUS, and Google Scholar for any date until January 10, 2021. All studies (n = 31) that reported black pleural effusion in patients were added to the review. Prospective Register of Systematic Reviews registration number: CRD42020213839. Summary and descriptive analysis was performed on Jamovi version 1.2.

RESULTS

The mean age of 32 patients with BPE was 53 years, with male predominance (69%). The commonest risk factor was smoking (n = 9) followed by alcohol intake (n = 8). Dyspnea was the commonest symptom (n = 24, 75%). Pleural fluid was mostly exudative (n = 21). The commonest associated diagnosis was malignancy (n = 14), with 50% secondary to metastatic melanoma. The commonest intervention was therapeutic thoracocentesis (n = 25, 78%), and the effusion recurred in half of the cases where recurrence was reported (n = 13). In our review, we found the mortality rate to be at 20.8% (n = 20.8%). 58.3% of the patients were successfully treated and discharged home (n = 14).

CONCLUSION

Although rare, BPE appears to be a relevant symptom as it seems to be frequently associated with modifiable risk factors and underlying malignancy. Our systematic review substantiates a vital research gap as observational research is imperative to characterize BPE further and form a basis for designing tailored diagnostic, preventive, and therapeutic strategies for BPE.

Images of the month 1: 'Soy sauce' pleural effusion: what causes black pleural fluid?

We present a case of black pleural fluid following thoracic trauma. The unusual dark colour most strikingly resembled soy sauce as independently commented upon by multiple treating physicians. The black colouration could not be fully accounted for by haemothorax or cholethorax, so other differential diagnoses were investigated, including Aspergillus niger infection and malignant melanoma. The cause, however, was thought to be due to staining of the fluid with carbon deposited in the pleural space from the non-volatilised impurities from smoking crack cocaine. A novel use of a point-of-care urine toxicology assay confirmed the presence of cocaine in the pleural fluid. Considering a broad range of differential diagnoses is needed to avoid missing important causes of unusual pleural effusions.

Small Cell Variant of Metastatic Melanoma: A Mimicker of Lymphoblastic Leukemia/Lymphoma

It is well-known to pathologists that melanoma is "the great mimicker" and can look like anything. Despite this widespread awareness, the diagnosis remains a continuous challenge, especially when a metastatic melanoma with rare morphology is examined. We report a case of a 64-year-old man with a lung mass and right-sided pleural effusion who underwent video-assisted thoracoscopic surgery for pleural decortication. The history of melanoma was not reported to us. Microscopic examination revealed sheets of small round blue cells infiltrating into the adipose tissue in a lace-like pattern mimicking lymphoblastic lymphoma. Immunohistochemical stains for melanocytic markers, including S-100 protein, Mart-1, and HMB-45, highlighted the neoplastic cells. The tumor was also positive for CD56 and CD117, but negative for pancytokeratin, CD45, cytokeratin 8, TTF-1, WT1, CD34, chromogranin, synaptophysin, and neuron-specific enolase. The findings were most consistent with metastatic small cell melanoma, an uncommon variant of melanoma that closely resembles lymphoblastic lymphoma and other malignant small round blue cell tumors. To our knowledge, we are the first to describe a case of metastatic small cell melanoma to the pleura in an adult. Clinical and histological details are provided with a review of the literature.

Iatrogenic Bilothorax: A Rare Complication of Orthotopic Liver Transplant

Bilothorax is a rare condition involving drainage of bile from the biliary system into the lung's pleural space. Several cases have been reported in the literature, where the most commonly reported cause is iatrogenic injury. To date, no cases of bilothorax as a complication of liver transplantation have been reported. Given its rarity and concurrent morbidity, early recognition is paramount as this condition can quickly deteriorate into adult respiratory distress syndrome.

Black pleural effusion caused by pancreatic pseudocyst rupture

The images show the path of pancreatic pleural effusion from the pancreatic pseudocyst in a patient with alcoholic pancreatitis who presented with black pleural effusion, however, without symptoms. Pancreatic pseudocyst rupture rarely causes pleural effusion; however, it should be considered in patients with chronic pancreatitis with black pleural effusion.

Black pleural effusion: etiology, diagnosis, and treatment

Introduction

Black pleural effusion (BPE) is an extremely rare entity. This review aims to increase the attention of thoracic physicians and surgeons to the differential diagnosis and management of unfamiliar cases with BPE.

Methods

Searching MEDLINE, Pubmed, and Web of Science databases with the words of "black pleural effusion" in title/abstract yielded 86 articles relevant to the topic of the review. There were only 20 case reports describing BPE with different underlying causes.

Results

BPE may occur as a result of fungal Aspergillus niger or Rhizopus oryzae infection, metastatic melanoma, pancreaticopleural fistula (PPF), hemolysis after massive intrapleural bleeding, or other miscellaneous causes. A stepwise approach should be followed for diagnosis of BPE including chest x-ray, diagnostic thoracocentesis, cytology and culture of the pleural fluid, thoracic or thoraco-abdominal computed tomography (CT), and tissue biopsy for pathological examination. Pleural fluid drainage is a sufficient treatment of BPE in most of the cases, and pleurodesis can be performed as part of palliative care. The definite treatment of the underlying causes of BPE, namely, pulmonary aspergillosis, metastatic melanoma, pulmonary adenocarcinoma, or PPF, is mandatory to achieve favorable outcome.

Conclusions

BPE is not a common clinical condition which may hide a critical disease including invasive pulmonary aspergillosis, metastatic melanoma, lung cancer, and PPF, thus awareness of this rare entity is crucial to prevent subsequent complications and to avoid delayed diagnosis of the underlying cause.

Black pleural effusion due to pancreatic pseudocyst: A case report

RATIONALE

Black pleural effusion (BPE) is an extremely uncommon type of pleural fluid, which can be due to infection, primary or metastatic malignancy, and hemorrhage. As reported in previous studies, BPE is also observed in some patients with pancreatic pseudocyst.

PATIENT CONCERNS

We herein reported a case of a 14-year-old female patient who was admitted to our center with a history of cough for 1 and a half months and right chest pain for 1 month. Before this, she was consecutively hospitalized in 3 different hospitals due to the same symptoms. However, the previous treatments were ineffective due to the lack of a definitive diagnosis. Laboratory examination of the pleural effusion showed BPE with a high amylase concentration. Chest x-ray and computed tomography (CT) showed massive pleural effusion, more prominent in the right chest. CT and MRCP of the abdomen showed a cystic lesion located in the tail of the pancreas, which entered the chest cavity via an esophageal hiatal hernia. DIAGNOSES:: pancreatic pseudocyst.

INTERVENTIONS

After confirming that the tumor was a pancreatic pseudocyst by intraoperative biopsy, internal drainage to the jejunum was performed.

OUTCOMES

The postoperative recovery was rapid and without complications, and the final discharge diagnosis was idiopathic pancreatic pseudocyst (without history of pancreatitis or pancreatic injuries) with BPE of the right chest.

LESSONS

This case demonstrates that massive BPE could present as a rare complication of pancreatic pseudocyst, and surgery is a potential treatment for such patients.

Recurrence of malignant melanoma presenting as black-colored pyopneumothorax: a rare entity

We report a 63-year-old patient with black-colored pus (pyopneumothorax) resulting from an infected pleural effusion associated with metastatic malignant melanoma of the skin. The patient was also positive for Pseudomonas, so the color was unexpected. Although rare, malignant melanoma can present as a black pleural effusion due to the presence of melanocytes in the pleural fluid. Black pleural fluid should raise the suspicion of malignant melanoma.

SIMILAR CASES PUBLISHED

Nine cases of black pleural effusion due to different causes have been reported.1,2 Three cases of black pleural effusion due to metastatic malignant melanoma are published.2,6,7.

Left pleural effusion caused by pancreaticopleural fistula with a pancreatic pseudocyst

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis. The authors described a case of a man with medical history of alcohol-related chronic pancreatitis, presented with dyspnoea. The roentgenogram showed a massive left pleural effusion. Additional work-up revealed a pancreaticopleural fistula and amylase-rich pleural effusion. His respiratory state improved after the insertion of chest drainage tube. During his admission, conservative and endoscopic therapy was required for the treatment of his complication of mediastinal abscess and arterial aneurysm in the pancreatic pseudocyst.

A new diagnostic approach for bilious pleural effusion

BACKGROUND

Bilious pleural effusion is an extremely rare condition associated with liver diseases, subphrenic or subhepatic abscess formation, biliary peritonitis, and invasive procedures (i.e., percutaneous biliary drainage or liver biopsy). The current diagnostic test is based on the measurement of the ratio of pleural total bilirubin to serum total bilirubin, which is greater than 1 in patients with bilious pleural effusion. Given the low incidence of bilious pleural effusion, the precise diagnostic yield of this ratio based test has not been evaluated.

METHODS

We retrospectively reviewed the medical records of our institution and searched the PubMed database for reports of bilious pleural effusion.

RESULTS

We identified a total of 12 cases of bilious pleural effusion (9 from 8 Pubmed reports and 3 from our institutional records). The factors causing this condition were broadly classified into three categories based on the pathophysiology: 1) liver diseases (echinococcosis, tuberculosis and amebiasis); 2) subhepatic/subphrenic abscess or biliary peritonitis, with or without biliary tract obstruction; and 3) iatrogenic disease after percutaneous biliary drainage and/or liver biopsy. The sensitivity of detection was 76.9% when the ratio of pleural total bilirubin to serum total bilirubin was greater than 1. The sensitivity increased to 100% when a combination test including pleural glycoholic acid was adopted.

CONCLUSIONS

This study demonstrates the high diagnostic yield for bilious pleural effusion using a combination of two test criteria; a ratio of pleural total bilirubin to serum total bilirubin greater than 1 and the presence of pleural glycoholic acid.

Black Urine and Black Pleural Fluid: A Distinctive Presentation of Metastatic Melanoma

Metastatic melanoma is an uncommon clinical entity which can have an unusual presentation. We describe a patient with metastatic melanoma who presented with diffuse melanosis cutis, black urine and black pleural effusion. Very few medical conditions can cause black discoloration of body fluids, so this should prompt physicians to search for a number of potential underlying causes.

Black Pleural Effusion: A Unique Presentation of Metastatic Melanoma

Metastatic melanoma is a rare form of skin cancer, but one that comes with a high mortality rate. Pulmonary involvement is frequently seen in metastatic melanoma with only 2% of malignant melanoma patients with thorax metastasis presenting with pleural effusions. Herein, we report an extremely rare case of black pleural effusion from thoracic metastasis of cutaneous malignant melanoma. A 74-year-old man with known metastatic melanoma presented with a 1-month history of worsening lower back and hip pain and was found to have extensive osseous metastatic disease and multiple compression fractures. The patient underwent an uneventful kyphoplasty; however, the following day, he became acutely hypoxic and tachypneic with increased oxygen requirements. Radiographic evaluation revealed new bilateral pleural effusions. Bedside thoracentesis revealed a densely exudative, lymphocyte-predominant black effusion. Cytological examination showed numerous neoplastic cells with melanin deposition. A diagnosis of thoracic metastasis of malignant melanoma was established based on the gross and microscopic appearance of the pleural fluid. To the best of our knowledge, this is the first reported case of black pleural effusions secondary to metastatic melanoma in the United States. Despite the rarity of this presentation, it is important to determine the etiology of the black pleural effusion and to keep metastatic melanoma as a differential diagnosis.

Aspergillus Niger Infection Associated with Systemic Oxalosis: An Autopsy Diagnosis Without Culture

This case report presents a 60-year-old male with a past medical history that included diabetes mellitus type II, chronic alcoholism, Hepatitis C infection, and presumptive pneumonia who died following a cholecystectomy. At autopsy, in addition to sequelae of the alcohol use (e.g., cirrhosis, splenomegaly, and esophageal varices), two contiguous black discolorations in the right lung composed of friable material and identified as fungal hyphae were found. Associated with the fungal hyphae was oxalic acid deposition. Oxalate crystals were also identified in the kidney of the decedent. Although no fruiting bodies were identified and no cultures were performed, a diagnosis of Aspergillus niger was made based upon the grossly apparent pigment production, lack of pigment within the fungal hyphae, and the oxalic acid production. Systemic oxalosis can occur as a result of an Aspergillus niger infection, and, its presence in the kidney would explain the decedent's worsening renal function prior to death.

Calcium oxalate crystal deposition in a patient with Aspergilloma due to Aspergillus niger

Discrimination between aspergilloma and chronic necrotizing pulmonary aspergillosis (CNPA) based on radiological findings can difficult. We describe a patient with aspergilloma and organizing pneumonia that was possibly caused by Aspergillus niger infection and radiologically mimicked CNPA. A postmortem histological analysis showed diffuse alveolar damage that had originated in peri-cavitary lung parenchyma. Calcium oxalate or Aspergillus niger was located inside, but not outside the cavity in the right upper lobe. Calcium oxalate or other unknown hyphal bioactive components might provoke severe lung inflammation not only adjacent to the cavity, but also on the contralateral side.