Acute pyopericardium due to tuberculosis is uncommon even in high prevalence countries. We report an unusual case of acute pyopericardium with cardiac tamponade complicating tuberculosis pneumonia of lingula in an adult. Prompt catheter drainage of pyopericardium under echocardiographic guidance and six month course of anti-tuberculosis treatment resulted in complete recovery without any sequelae during the follow-up period of ten months.

A-50-year old male chronic alcoholic and smoker was admitted to our inpatient department of Narayana medical college hospital with pleuritic chest pain, exertional breathlessness and epigastric pain with vomiting of ten days duration. There was history of hypertension and diabetes mellitus for the past three years. Patient stopped drinking alcohol one year back after an episode of acute abdomen. There was history of anti-TB therapy for one month for left sided exudative pleural effusion without much relief. Physical examination findings were not very significant. Chest examination showed bilaterally decreased breath sounds. Urinalysis revealed proteinuria and glycosuria. Routine blood counts were not significant. Blood chemistry showed total bilirubin of 1.87 mg% and random blood sugar of 264 mg%. HIV and viral hepatitis serology were negative. A chest radiograph [Table/ Fig-1] showed left sided cyst like opacities and bilateral pleural effusion. An abdominal ultrasound revealed enlarged pancreas. Cardiac work up was negative. A computed tomographic (CT) scan of chest [Table/ Fig-2] revealed bilateral pleural effusion, intercommunicating cystic lesions in the left pleural cavity and posterior mediastinal pseudocysts. Serum level of amylase was 942 U/L (normal <220 U/L), lipase was 185 U/L (normal 13-60 U/L) and protein was 6.5 g/dl. At pleural tap, pleural fluid was brownish and had protein level of 3.7 g/dl, lactose dehydrogenase (LDH) level of 1050 U/L (normal<220 U/L) and 70% lymphocytes. Pleural fluid adenosine deaminase (ADA) level was 40U/L (normal <40 U/L) and amylase level was 3392 U/L (normal <220 U/L). All other pleural fluid reports were negative. Upper abdominal section of contrast enhanced CT scan showed a pseudocyst around the enlarged pancreas with calcifications in the head and body regions (Black arrows). Initial therapeutic pleural aspiration on left side was followed by rapid reaccumulation of pleural fluid within four days and tube thoracostomy was done. Patient responded well to treatment with cefoperazone plus salbactum, parenteral nutrition and pleural drainage. Check radiograph of chest [Table/ Fig-4] showed complete lung expansion on left side but check CT [Table/ Fig-5] showed persistence of mediastinal pseudocysts. A diagnosis of bilateral pleural effusion with thoraco-abdominal pancreatic pseudocysts complicating chronic pancreatitis was made and the patient was referred to surgical gastroenterologist for further management.Massive recurrent pleural effusion in chronic calcifying pancreatitis and pseudocyst is rare [1]. Mediastinal pseudocysts with recurrent bilateral pleural effusion in chronic pancreatitis are very rare [2]. Pancreatitis may cause pleural effusion if inflammation spreads directly into thoracic cavity through the diaphragm or extends into mediastinum through diaphragmatic openings or if pancreaticopleural fistula (PPF) develops between the ruptured pancreatic duct or pseudocyst and the pleural cavity [3]. A posterior mediastinal pseudocyst results if pancreatic duct...

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