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Case Report

Case 1

A 47-year-old male presented with shortness of breath, intermittent hemoptysis and chest pain of 6 months duration. He had a history of pancreatitis 3 years back. A chest radiograph showed massive left sided pleural effusion, for which he underwent intercostal drainage. The pleural fluid was hemorrhagic with amylase level of 6200 U/L (reference range: 0-180 U/L), protein 5 g/dL (reference range: 0-3.5 g/dL) and adenosine deaminase 22 U/L (ADA; reference range: 0-32 U/L). Cytology for malignant cells was negative, gram staining and culture showed no acid fast bacilli. Blood examination showed serum amylase levels of 230 U/L (reference range: 0-100 U/L).

Imaging findings-Contrast enhanced CT study showed moderate left pleural effusion with underlying lung collapse and intercostal drain tube in situ. Pancreas was atrophic with dilated main pancreatic duct (~4mm) and multiple calcific foci in head and body (Figure 1A). Multiple small peripherally enhancing collections were seen in lesser sac and around the esophagus in lower mediastinum communicating with the main pancreatic duct and left pleural space, suggestive of pancreaticopleural fistula (Figure 1B, Figure 1C).

Management-Patient was treated conservatively by intercostal drainage of pleural effusion and administration of octreotide. Post treatment follow up for 6 months revealed no recurrent effusion.

Case 2

A 44-year-old man, with increasing dyspnea, mild epigastric discomfort and anorexia for three months prior to hospitalization, was admitted to our hospital. Past medical history was relevant for chronic alcoholic pancreatitis. Prior to admission, patient had been diagnosed with a left pleural effusion at a district level hospital where he had undergone a therapeutic pleural tap twice and received antibiotics.

Physical examination was suggestive of a notable pleural effusion in the left pleural cavity and only mild pain was elicited on deep palpation in the epigastric region. Laboratory data were as follows: serum amylase 323 U/L (reference range: 8-53 U/L), lipase 516 U/L (reference range: 8-78 U/L) and calcium 7.9 mg/dL (reference range: 9-10.5 mg/dL). No biochemical signs of cholestasis or hepatocellular damage were found.

Chest radiograph in our hospital revealed gross left pleural effusion. Abdominal ultrasound showed an atrophic pancreas and a round fluid collection located in the superior aspect of pancreatic body. Pleural fluid analysis revealed amylase level of 12540 U/L (reference range: 0-180 U/L) and protein 4.7 g/dL (reference range: 0-3.5 g/dL). With the clinical suspicion of a pancreaticopleural fistula, further evaluation by Magnetic Resonance cholangiopancreatography (MRCP) was carried out.

Imaging findings-Abdominal MRCP was performed by a 1.5 T unit with a phased-array body coil. We used heavily T2-weighted sequences: a Half-Fourier Single-shot Turbo spin-Echo (HASTE) 2D breath-hold and 3D respiratory gated Turbo Spin-Echo (TSE) with Multiplanar Reconstruction (MPR) and Maximum Intensity Projection (MIP). The entire pancreatic parenchyma was atrophic and replaced by fat. Main pancreatic duct was dilated with an intraductal hypointense filling defect (measuring ~2.2x1.2cm) in head region, suggestive of calculus (Figure 2A). A lobulated cystic lesion of ~3.3x4.2x5.8cm (mediolateral x anteroposterior x craniocaudal) was seen in the superior aspect of pancreatic body extending into the posterior mediastinum of thorax. It was seen to communicate with the main pancreatic duct and left pleural effusion, suggestive of pancreaticopleural fistula (Figure 2B,Figure 2C).

Management-Intercostal drainage of left pleural effusion was performed. Medical treatment was started with Total Parenteral Nutrition (TPN) and the administration of broad spectrum antibiotics, proton pump inhibitors and octreotide. The patient was discharged without dyspnea or abdominal symptoms in an improved general condition.