Case Presentation: A 77-year-old male with past medical history of hypertension, hyperlipidemia, stroke, subarachnoid hemorrhage, and obstructive hydrocephalus status post ventriculoperitoneal shunt (VPS) placement presented with altered mental status and fever. A CT head showed worsening hydrocephalus. VPS was aspirated, fluid was non-infectious. Patient was empirically treated with vancomycin and zosyn for presumed sepsis. His clinical condition continued to deteriorate and blood cultures grew Staph hominis, indicating bacteremia. CT Abdomen and Pelvis showed liver abscess and Abdominal Ultrasound showed acute cholecystitis. Chest x-ray (CXR) at this time was concerning for volume overload with pulmonary edema and bilateral pleural effusions. He underwent drainage of the hepatic fluid collection and percutaneous cholecystostomy tube placement. He was treated with broad spectrum antibiotics for acute cholecystitis and bacteremia. He underwent neurosurgical intervention for hydrocephalus. He continued to be hypoxic. CXR revealed interval increase of Right pleural effusion. He was diuresed, but subsequent imaging revealed persistent right pleural effusion. Thoracentesis was done. Pleural fluid studies showed exudative effusion with elevated bilirubin in the pleural fluid, consistent with bilothorax. The fluid was not fully evacuated as he could not tolerate the procedure, leading to an interdisciplinary discussion between cardiothoracic surgery, pulmonology, and primary internal medicine team on whether the patient needed intervention for this asymptomatic bilothorax. Ultimately, intervention was advised to due to concern for infection. Patient underwent placement of chest tube and was ultimately discharged after chest tube removal on six weeks of Augmentin.
Discussion: Common disease processes such as acute cholecystitis can have atypical and severe clinical manifestations that require prompt and timely diagnosis and treatment. Bilothorax is defined as the presence of bile in the pleural space, and it was first reported as a consequence of blunt force trauma in 1971. While the etiologies of bilothorax can be varied, the main presumption of the mechanism of bilious pleural effusion includes small perforations in the diaphragm that lead to the fenestration of these contents into the pleural space [1]. Bilothorax may also be an iatrogenic complication after surgical manipulation of hepatobiliary structures or after blunt force trauma to the chest [2]. The diagnosis of bilothorax is made when the fluid-to-serum bilirubin ratio is greater than 1.0. This requires a high index of clinical suspicion as pleural fluid bilirubin is not routinely checked. Early fluid drainage and prompt administration of broad-spectrum antibiotics are crucial for management [3] to prevent subsequent infection and progression to empyema and sepsis.
Conclusions: Bilothorax may arise as a complication of hepatobiliary tract surgery. Fluid studies including bilirubin are vital to diagnose the condition. Once confirmed, bilothorax requires drainage to prevent secondary infection and subsequent sepsis.