Indian Pediatrics 1999; 36:310-313 

Pancreaticopleural Fistula Presenting as Hemorrhagic Pleural Effusion

Hemorrhagic pleural effusions in child­hood are commonly associated with tubercu­losis, trauma, malignancies and collagen vascular disease(1). We present here a case of massive "hemorrhagic pleural effusion of a rare etiology.          

Case Report

A 9-year-old male child presented with a 12 day history of fever and dry cough. Two days prior to admission, the patient developed pleuritic pain over the right hemithorax. A history of being kicked in the abdomen by a school-mate about 2 months ago followed by mild abdominal pain was obtained later during the course of his hospital stay.

Examination revealed an undernourished febrile child with features of rightsided pleural effusion. Examination of the abdomen was normal. Chest X-ray confirmed the clinical finding of a right-sided pleural effusion. The pleural fluid was uniformly hemorrhagic and contained 8.8x10⁹ leukocytes, predominantly neutrophils, 4.8 g/dl proteins, 87 mg/dl glucose, no malignant cells and Was sterile on culture. The ESR was 48 mm/1st hour and the Mantoux test was negative.

He was initially started on intravenous antibiotics (cloxacillin and gentamicin). He became afebrile within 4 days and oral cloxacillin was continued for 4 weeks. However, his effusion persisted and reaccumulated rapidly after a therapeutic drainage (350 ml). An underlying tubercular etiology. was considered and he was put on anti-tubercular drugs (ATT).

Inspite of A IT the effusion persisted and required an intercostal tube drain. Initially, the drainage was around 100 ml/day, but gradu­ally decreased to 10-20 ml/day over 10 days. Chest X-ray done at this time showed good lung expansion. An ultrasound of the chest done to look for any residual fluid showed, in addition to the right pleural effusion, an anechoic collection in the region of the pancreas measuring 4.5x2.1 cm suggestive of a pancreatic psuedocyst with a communication to the pleural space (pancreaticopleural fistula) (Fig.1). Serum amylase was 47 Somogyi units and pleural fluid amylase 400 Somogyi units. CT scan abdomen showed 2 intrapan-creatic pseudocysts (Fig. 2), one of which was extending into the mediastinum and right pleural space (Fig. 3). Bilateral pleural effusions (R>L) were also seen.

He was managed conservatively with right intercostal tube drainage for 14 days. ATT was stopped. During his hospital stay, he developed super added infection of pleural fluid with pseudomonas aeruginosa which responded to parenteral antibiotics administered for 7 days. The child improved symptomatically and the pleural effusion resolved. He remained asymptomatic and was discharged after about 2 months of hospital stay. On follow up after 2^1/2 months, he remained asymptomatic and one ultrasound abdomen showed reduction in the cyst size. Subsequently he was lost to follow up.

 

Fig. 1. Ultrasound abdomen showing pancreatic cyst (Pan) and pleural collection  (PI) with the communicating tract (Tr).

 

Fig. 2. CT scan abdomen showing two pancreatic pseudocysts.

 

Fig. 3. CT scan chest showing mediastinal pseudocyst and bilateral pleural effusions (R>L).

 

Discussion

Tuberculous pleural effusion is a common cause of hemorrhagic pleural effusion in India. In the absence of an obvious cause, patients with hemorrhagic pleural effusion have been empirically started on ATT as was done in our patient(2).

Pancreatic pseudocysts have been infre­quently reported in the pediatric population(3). Pancreaticopleural fistula is an uncommon complication that occurs in 1-3% of cases of pancreatic pseudocysts in adults(4,5). However, the incidence in children is not known. Blunt abdominal trauma accounts for over 60% of the reported cases of pancareatic pseudocysts in children(3).

Pancreatic pleural effusions result from either a posterior disruption of the duct or a leaking pseudocyst(4-6). Spillage of pancre­atic secretions into the retroperitoneum occurs and these track along the aortic or esophageal hiatus into the mediastinum. The secretions may either get localized to form a mediastinal pseudocyst or rupture into one or both pleural cavities as pleural effusions. Anterior pancreatic ductal disruption, on the other hand, leads to pancreatic ascites(4,5).

While a diagnosis of pleural effusion of a pancreatic origin is based on a high amylase concentration(2,4-6) demonstration of pancreatic pseudocysts and pancreaticopleural fistula requires radiologic investigations(4). Ultrasound is useful in defining pancreatic pseudocysts; however CT scan is better in defining pancreatic abnormality and can often demonstrate pancreatic pseudocysts with direct extension into the pleural cavity(4,5). ERCP plays an important role in defining the ductal anatomy and fistula and is essential before surgical intervention( 4).

 References