University of Massachusetts Medical School Worcester, MA
Olivia Karcis, MD1, Irma Hashmi, DO2, Brooke McNeilly, DO2; 1University of Massachusetts Medical School, Worcester, MA; 2University of Massachusetts Medical Center, Worcester, MA
Introduction: Pancreaticopleural fistula is a rare and serious complication of acute pancreatitis. This phenomenon develops due to a leak from an incompletely formed or disrupted pseudocyst, though it can also result from direct pancreatic duct leak. Although few case reports identify pancreaticopleural fistula causing recurrent pleural effusion and empyema, we describe the unique case of pancreaticopleural fistula causing necrotizing pneumonia, a finding never before reported in the literature.
Methods: A 47-year old man presented for subacute, intermittent, severe left-sided pleuritic chest pain. Past medical history was significant for chronic alcoholic pancreatitis. This was complicated by pancreatic pseudocyst formation, for which the patient underwent cystgastrostomy. Laboratory values showed leukocytosis 16.7 cells/L, lipase 16 U/L, and normal liver function tests. CT chest demonstrated a necrotizing consolidation in the left lower lung. Additionally, a left-sided subphrenic collection extended from the pancreatic tail to the splenic hilum. The patient was initiated on intravenous antibiotics for necrotizing pneumonia. Diagnostic thoracentesis revealed Streptococcus constellatus, a gut bacterium, amylase 17,347 U/L, protein 5.2 g/dL, and LDH >12,000 U/L. Interval imaging demonstrated a thick-walled fluid collection from the pancreatic tail tracking directly to the pleural space, confirming a pancreaticopleural fistula. ERCP revealed a large distal pancreatic duct leak, repaired with plastic stent. The patient was discharged home with octreotide and recommendation to follow up with gastroenterology and transplant surgery. Discussion: Extremely rare and deceiving in presentation, pancreaticopleural fistulas often present with large-volume effusion that can progress to empyema. To the best of our ability, this is the first reported case of pancreaticopleural fistula leading to necrotizing pneumonia. Diagnosis of a pancreaticopleural fistula is with MRCP. Treatment is with stent placement for pancreatic duct leak. Few case reports also cite octreotide in management of the fistula, with surgical intervention reserved for those refractory to conservative management. In our case, the presence of a gut bacterium in the pleural space, along with the patient’s history, triggered further investigation of necrotizing pneumonia. To prevent such complications, a high index of suspicion is required in patients with complicated pancreatitis, in particular those presenting with pulmonary complaints.
Disclosures: Olivia Karcis indicated no relevant financial relationships. Irma Hashmi indicated no relevant financial relationships. Brooke McNeilly indicated no relevant financial relationships.