Case Presentation: Pancreaticopleural fistula is a rare and serious complication of acute and chronic 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.
Discussion: A 47-year old man presented for subacute, intermittent, severe left-sided pleuritic chest pain. Past medical history was significant for chronic alcoholic pancreatitis, complicated by pancreatic pseudocyst formation and chronic splenic vein thrombosis. Notably, three months prior to presentation, the patient had undergone cystgastrostomy for complicated pancreatic pseudocyst. On presentation, laboratory values were significant for leukocytosis 16.7 cells/L, lipase 16 U/L, and normal liver function tests. Initial computed tomography (CT) chest showed necrotizing consolidation in the left lower lung lobe. 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 growth of Streptococcus constellatus, a gut bacterium, amylase 17,347 U/L, protein 5.2 g/dL, and LDH >12,000 U/L. Interval imaging with CT abdomen and pelvis demonstrated a thick-walled fluid collection from the pancreatic tail tracking directly to the pleural space, confirming a pancreaticopleural fistula. The patient underwent endoscopic retrograde cholangiopancreatography, which 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 for continued monitoring of the pancreatic duct leak.
Conclusions: Extremely rare and deceiving in their presentation, pancreaticopleural fistulas often present with large-volume effusion that can progress to empyema. To the best of our ability, our case is the first reported case of pancreaticopleural fistula leading to necrotizing pneumonia. Magnetic resonance cholangiopancreatography is the best modality to diagnose a fistulous tract and guide therapeutic management. Additionally, pleural fluid amylase should be obtained to support the diagnosis of pancreaticopleural fistula. Treatment is with stent placement for pancreatic duct leak. Few case reports also cite the use of 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 and a recent history of pancreatic pseudocyst formation requiring cystgastrostomy.