Evaluation of pleural fluid revealed hemorrhagic, lymphocyte predominant exudate with low Adenosine Deaminase ADA and high amylase level. Ascitic fluid too showed similar characteristics. His serum amylase level was also elevated which prompted us to make a clinical diagnosis of pancreatic pleural effusion with ascites.
Further radiological investigations confirmed the diagnosis of acute pancreatitis. Early pleural fluid amylase testing will certainly avoid a delay in the timely diagnosis.
Keywords: Amylase, hemorrhagic pleural effusion, pancreatitis, pseudocyst. Users Online Sumalata C, Gopichand N. An unusual presentation of pancreatic pleural effusion. Sch J Med Case Rep ; Pleural effusions: A new negative prognostic parameter for acute pancreatitis. Am J Gastroenterol ; Bedi RS. Massive pleural effusion due to asymptomatic pancreatic disease. Lung India ; Aswani Y, Hira P.
Pancreaticopleural fistula: A review. JOP ; Pancreaticopleural fistula. Report of 7 patients and review of the literature. Learn More. Sign in via OpenAthens. Sign in via Shibboleth. AccessBiomedical Science. AccessEmergency Medicine.
Case Files Collection. Clinical Sports Medicine Collection. Davis AT Collection. Davis PT Collection. Murtagh Collection. About Search. Enable Autosuggest. You have successfully created a MyAccess Profile for alertsuccessName. Home Books Quick Answers Surgery. The cause of pancreatitis could not be identified. Pancreatitis should be taken into consideration when hemorrhagic pleural effusion, especially in the right hemithorax occurs.
Peer Review reports. Hemorrhagic pleural effusion, especially in the right hemithorax, rarely occurs as the sole manifestation of pancreatitis [ 1 — 6 ]. Most cases of hemorrhagic pleural effusion secondary to pancreatitis are between the ages of 20 to 55, and patients are alcohol drinkers [ 2 , 5 ]. This year-old boy, from a village in Fars Province, Southern Iran, developed left paraumblical sometimes epigastric abdominal pain with moderate intensity about five months prior to admission.
The pain subsided after three months. However, 20 days later, the patient developed right-sided shoulder and chest pain accompanied with dyspnea. The patient's severe shoulder pain was mismanaged by a physician who considered it musculoskeletal pain. The patient then referred to Nemazee Hospital, the main hospital of southern Iran.
Acid fast staining ofpleural fluid was negative three times. The results of pleural biopsy and pleural fluid culture for Tuberculosis were negative as well. Important peripheral blood laboratory values were as follows: hemoglobin: 9. Pleural fluid cytology three times and bronchial washing cytology were also negative. Due to markedly elevated serum and pleural fluid amylase abdominal CT scan was done 2 days after insertion of chest tube at the 8th day of hospitalization.
Also, abdominal ultrasonography revealed a small septated cystic structure in the head of the pancreas which was edematous and suggestive of pseudocyst of acute pancreatitis. Hepatobiliary tract and gall bladder were devoid of any gall bladder lesions, including stones. The patient had no history of drug and alcohol intake or abdominal trauma. Chest tube was inserted for three weeks, during this period the clinical symptoms such as dyspnea and chest pain improved but not completely.
Thedaily drain output was about cc at the first day of chest tube insertion but it decreased gradually. No evidence of pancreatic duct dilatation or common bile duct dilatation was seen. Therefore external psendocyst drainage was done with mushroom insertion.
Mushroom was removed after one week when no drainage was seen. Finally the patient was discharged after 40 days of hospitalization. Intrathoracic neoplasms, trauma, bleeding diathesis or tuberculosis may cause hemorrhagic pleural effusion as well [ 1 ]. Right-sided hemorrhagic pleural effusion as the sole manifestation of pancreatitis is rare [ 1 — 4 , 6 , 7 ] especially when it occurs in the non-alcoholic patient under the age of 20 [ 2 , 3 ].
The postulated pathogenic mechanisms for hemorrhagic effusions include transdiaphragmatic transfer of fluid via lymphatics, diaphragmatic perforation of pseudocyst and mediastinal extension [ 1 ]. Several studies demonstrated that a fistula connecting a pancreatic pseudocyst with pleural cavity was the mechanism of pleural effusion [ 4 , 7 ]. Although the cause of pancreatitis could not be identified in our study, other studies have shown that pleural effusion with a very high pancreatic enzymes activity most frequently occurs in patients with alcoholic pancreatitis [ 5 , 8 — 10 ].
Pleural effusions due to pancreatic diseases are mostly reactive with slightly elevated amylase levels. Very high levels of amylase in the pleural fluid are rare and can only be explained by the rupture of a pancreatic pseudocyst with perforation into the pleural cavity such as by drainage of pancreatic fluid into the pleural cavity [ 11 ].
Regarding elevated pleural fluid amylase, perforation of pseudocyst into the pleural cavity seems to be the mechanism of hemorrhagic pleural effusion in this case. The other causes of hemorrhagic effusions with an increased amylase include traumatic esophageal rupture and intrathoracic and other neoplasms [ 1 ].
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