Pancreaticopleural Fistula- A Rare Cause of Haemorrhagic Pleural Effusion

Abstract

HOW TO CITE THIS ARTICLE: PRESENTATION OF CASEA 10-year-old boy presented with complaints of pain abdomen for 8 months, which had increased in severity for 15 days prior to admission along with fever, difficulty in respiration and right-sided dull aching chest pain. On examination, he was pale and tachypnoeic with a normal nutritional status. The trachea was shifted towards left, stony dullness was noted on percussion and breath sounds were decreased on the right side of the chest. Tenderness was present over epigastrium and right hypochondrium. CLINICAL DIAGNOSISClinically, the case was diagnosed as right-sided bacterial pleural effusion with chronic abdominal pain. Further investigations were planned to confirm the diagnosis and to find out the aetiology. DIFFERENTIAL DIAGNOSISDifferential diagnoses can be tubercular pleural effusion or haemorrhagic pleural effusion (rare). Differential diagnoses of pain abdomen can be hepatic abscess, right subphrenic abscess, pancreatic pseudocyst and acute or chronic pancreatitis. So immediate chest x-ray and pleural tapping were planned. PATHOLOGICAL AND RADIOLOGICAL DISCUSSIONRoutine blood examination showed Hb 12.3 gm%, TLC 18,800/mm3 with 87% neutrophils and ESR 30 mm AEFH. Chest X-ray showed total homogenous opacification of the right hemithorax with gross mediastinal shift towards the left. On aspiration, pleural fluid was found to be haemorrhagic. Pleural fluid analysis showed protein 3.8 gm/dL, sugar 40 mg/dL, cell count 580 cells/cumm, mostly lymphocytes and presence of plenty of RBCs. There were no malignant cells. ADA was normal. Culture of pleural fluid showed growth of Acinetobacter baumannii. Tuberculin test was negative. PT, APTT, INR and platelet count were normal. Common causes of haemorrhagic pleural effusion are malignant effusion (most commonly Lymphoma), traumatic effusion, tubercular effusion or bleeding diathesis. The patient was started empirically on Vancomycin, which was changed to Imipenem later as per the sensitivity report.