LAUSR

A 62-year-old woman presented to the hospital with the complaints of right upper abdominal pain and dyspnea for the past 3 days. She described the pain as dull, constant, and radiating to her back and right side of the chest. She also complained of progressive dyspnea, both on rest and on exertion. She has been feeling nauseated, but denied any vomiting. She had a past medical history of stage-IV adenocarcinoma of the pancreas diagnosed 3 years prior, and had received palliative chemoradiation treatment. She also had recurrent episodes of biliary obstruction with jaundice with the evidence of common bile duct (CBD) obstruction by the mass on previous imaging. One week prior, she underwent percutaneous transhepatic biliary drain (PTBD) catheter and endoscopic retrograde cholangiography (ERCP) guided self-expandable metallic stent (SEMS) placement in the common bile duct (CBD) to relieve biliary obstruction. The PTBD catheter was removed following the stent placement. Vital signs at the time of presentation were temperature 37 °C, heart rate 76 beats/min, blood pressure of 135/99 mmHg, respiratory rate 22 breaths/min, and oxygen saturation 98% on 3 l of oxygen by nasal cannula. Physical examination showed a thin, cachectic female in moderate distress. Precordial examination showed normal S1 and S2 without any murmurs. Pulmonary examination showed dullness to percussion on the right side along with decreased breath sounds in the right-middle and -lower quadrant on auscultation. Abdominal examination showed a soft, nondistended abdomen with a gastrostomy tube, and tenderness to palpation in the right upper quadrant. A chest radiograph showed opacification of the right-mid and -lower lung zone consistent with a moderate-to-large right-sided pleural effusion (Fig. 1a). A CT scan of the chest confirmed the presence of a large right-sided pleural effusion (Fig. 1b). A thoracentesis was performed, and the drained fluid appeared grossly bilious (Fig. 1c). The metallic biliary stent is not visible in the images. Fluid analysis showed total bilirubin to be 16 mg/dl in the pleural fluid with a serum total bilirubin of 0.9 mg/dl. The fluid was an exudate by Light’s criteria with an LDH of 4446 U/l, glucose of 10 mg/dl, and pH of 6.92. A video-assisted thoracotomy was done with the drainage of pleural fluid and decortication of the adjacent right lung. Gram’s stain and cultures from the pleural fluid and lung tissue showed polymicrobial infection with Klebsiella and Streptococcus. A diagnosis of pyocholethorax was established resulting from the penetration and injury of the pleura by the PTBD catheter with the formation of a biliary pleural fistula and superimposed infection. The patient was started on i.v. ceftriaxone and metronidazole. Repeat chest radiographs showed improvement in the pleural effusion with re-expansion of the right lung. She recovered well, and was discharged home.