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Saleh Z, Pawar R, Pillai A, Abdelwahed A, Ibrahim O. Pancreatitis as a Pulmonary Pathology: A Rare Case of a Pancreaticopleural Fistula Presenting as Recurrent Pleural Effusions Causing Mediastinal Shift. Cureus 2024; 16:e64246. [PMID: 38988902 PMCID: PMC11235154 DOI: 10.7759/cureus.64246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 07/12/2024] Open
Abstract
Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis and pancreatic pseudocyst. It can present as recurrent pleural effusions and can be difficult to diagnose and treat. We present the case of a 37-year-old male with a history of chronic idiopathic pancreatitis complicated by a pseudocyst who came in with progressive dyspnea, cough, and pleuritic chest pain. The chest X-ray on presentation showed near-complete opacification of the left hemithorax, suggesting a large pleural effusion. Upon thoracentesis, black-bloody fluid was drained, and the pleural fluid analysis was consistent with an exudate with significantly elevated levels of amylase, lipase, and bilirubin. Cytology revealed abundant lipofuscin-laden macrophages, suggesting an intra-abdominal source of the accumulated fluid. A post-drainage CT of the chest showed the resolution of the pleural effusion and an interval decrease in the pancreatic pseudocyst size, indicating a fistulous connection to the pleural space. An endoscopic ultrasound (EUS) was performed with efforts to perform cystogastrostomy aspiration that was hindered by the interference of splenic vasculature obstructing the needle's path. The patient was transferred to another facility for definitive treatment with surgical pancreatectomy and auto islet cell transplant. This case underscores the importance of considering PPF as a possible diagnosis, especially in cases of recurrent pleural effusions and a history of pancreatitis and pancreatic pseudocyst. It also emphasizes the significance of EUS as the preferred modality for pseudocyst evaluation and its potential for minimally invasive treatment.
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Affiliation(s)
- Zidan Saleh
- Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Resham Pawar
- Pulmonary, Critical Care, and Sleep Medicine, University of Connecticut Health, Farmington, USA
| | - Ashwin Pillai
- Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Ahmed Abdelwahed
- Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Omar Ibrahim
- Pulmonary, Critical Care, and Sleep Medicine, University of Connecticut Health, Farmington, USA
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3
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Benjamin J, O'Leary C, Hur S, Gurevich A, Klein WM, Itkin M. Imaging and Interventions for Lymphatic and Lymphatic-related Disorders. Radiology 2023; 307:e220231. [PMID: 36943078 DOI: 10.1148/radiol.220231] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.
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Affiliation(s)
- Jamaal Benjamin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Cathal O'Leary
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Saebeom Hur
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Alexey Gurevich
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Willemijn M Klein
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Maxim Itkin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
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4
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Bouassida I, Hadj Dahmane M, Zribi H, Abdelkbir A, Jaber C, Marghli A. Pyo pneumothorax revealing splenic tuberculosis abscess in a COVID-19 femmal: A case report. Int J Surg Case Rep 2022; 96:107312. [PMID: 35749946 PMCID: PMC9212807 DOI: 10.1016/j.ijscr.2022.107312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/11/2022] [Accepted: 06/12/2022] [Indexed: 02/07/2023] Open
Abstract
In areas where tuberculosis is prevalent, a splenic tuberculosis should be considered in the differential diagnosis of patients presenting with fever of unknown origin and splenomegaly. The diagnosis can be made later when complications occur as well as spontaneous rupture of the spleen. Although rare, chest rupture can occur and symptoms can be respiratory as well as pyopneumothorax or empyema, which can lead to inaccurate diagnosis and inappropriate treatment of the an underlying condition.
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Affiliation(s)
- Imen Bouassida
- Thoracic Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia
| | - Mariem Hadj Dahmane
- Thoracic Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia,Corresponding author at: Thoracic Surgery Department, Abderrahmen Mami Hospital, Street of hospital, 2080 Ariana, Tunisia.
| | - Hazem Zribi
- Thoracic Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia
| | - Amina Abdelkbir
- Thoracic Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia
| | - Chaker Jaber
- Cardiovascular Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia
| | - Adel Marghli
- Thoracic Surgery Department, Abderahmen Mami University Hospital, Ariana, Tunisia,Tunis El Manar University, Tunisia
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Ayoub M, Ochoa J, Cibich D, Gupta M. Pancreaticopleural Fistula: A Rare Complication of Alcoholic Pancreatitis. Cureus 2021; 13:e18729. [PMID: 34796046 PMCID: PMC8589337 DOI: 10.7759/cureus.18729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/06/2022] Open
Abstract
Pancreaticopleural fistula (PPF) is an uncommon complication of chronic pancreatitis. The authors describe a case of a 41-year-old male with a history of chronic alcoholic pancreatitis and pancreatic pseudocyst who presented with dyspnea and right-sided chest pain for three days. A chest radiograph showed near-complete opacification of the right hemithorax. A diagnostic thoracentesis revealed an exudative, amylase-rich pleural effusion. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a normal appearance of the ampulla of Vater and common bile duct; however, there was disruption of the pancreatic duct with leaking beyond the pancreatic neck. A sphincterotomy was performed, and a double-flanged stent was placed, which resulted in the resolution of the dyspnea and the right-sided pleural effusion.
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Affiliation(s)
- Malek Ayoub
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Janna Ochoa
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Daniel Cibich
- Diagnostic Radiology, Medical College of Wisconsin, Milwaukee, USA
| | - Mrigank Gupta
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
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7
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Abstract
Classically, both chylothorax and pseudochylothorax present as a pleural effusion with a characteristic milky white appearance to the pleural fluid. Although both are rare causes of pleural effusion, they have distinct etiologies and clinical implications, and as a result require different management strategies. Pleural fluid analysis of cholesterol and triglyceride levels is key to differentiating the 2 entities from one another and then guide the clinician to determine the best next steps in evaluation and management.
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Affiliation(s)
- Cassandra M Braun
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18 South, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Gonda 18 South, 200 First Street, Southwest, Rochester, MN 55905, USA.
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8
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Hopkins D, Pattman S, Jones R, Aujayeb A. A left-sided cerebrospinal fluid hydrothorax and a right ventricular-peritoneal shunt: a unique clinical case study. BMJ Case Rep 2019; 12:12/9/e230236. [PMID: 31540921 DOI: 10.1136/bcr-2019-230236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
We describe the case of a 84-year-old woman with a right ventricular-peritoneal shunt and a left-sided pleural effusion, the analysis of which was positive for cerebrospinal fluid. We consider the potential causative mechanisms. Our patient was managed conservatively due to her frailty, the effusion being asymptomatic and her preference not to pursue further invasive diagnostic testing. This case report is unique due to the contralateral nature of the effusion to the shunt, which has not been described before in the literature.
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Affiliation(s)
- David Hopkins
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Stewart Pattman
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Rhian Jones
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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9
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Casallas A, Castañeda-Cardona C, Rosselli D. Urinothorax: Case report and systematic review of the literature. Urol Ann 2016; 8:91-4. [PMID: 26834411 PMCID: PMC4719522 DOI: 10.4103/0974-7796.164851] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Urinothorax, the presence of urine in the pleural space, is a rare cause of pleural effusion, usually associated with obstructive uropathy, or urinary trauma. We present the case of a 3 year-old boy and a systematic review of the literature of the 44 cases encountered. After resection of a Wilm's tumour in the right kidney our patient presented acute respiratory distress associated with radiographically confirmed pleural effusion. With the initial diagnosis of pneumonia or malignant pleural effusion, a closed thoracotomy was performed. The liquid obtained suggested urine, which was confirmed by the laboratory. Cystoscopy with retrograde pyelography detected a fistula on the posterior wall of the right kidney. The report of cases worldwide is low, probably due to its low incidence but also to underdiagnosis. Respiratory symptoms are not always present and urological symptoms usually predominate. Diagnosis requires a high degree of clinical suspicion and is confirmed by the main biochemical marker: The ratio >1.0 pleural fluid creatinine and creatinine serum.
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Affiliation(s)
- Alexander Casallas
- Department of Clinical Epidemiology and Biostatistics, Clínica Infantil Colsubsidio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Camilo Castañeda-Cardona
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Diego Rosselli
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogota, Colombia
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