Abstract Introduction Amylase-rich pleural effusions (ARPE) are rare and suggestive of the following underlying etiologies: pancreaticopleural fistula (PPF), esophageal rupture, or malignancy (e.g. lung adenocarcinoma, in addition to other neoplasms)1-3. Although recurrent acute pancreatitis may suggest a source for ARPEs, their origin can remain unclear in the absence of a visible fistula or pancreatic pseudocyst. Nonetheless, such effusions are associated with a poor prognosis and increased risk of complications, including fistula formation and pseudocyst development4,5. Case Presentation A 62-year-old male with history of chronic, necrotizing pancreatitis, COPD and alcohol use disorder (quit 3 months prior), and emphysema presented with hemoptysis and progressive dyspnea. 3 weeks prior, he had undergone thoracentesis for large left-sided pleural effusion. On admission, he was tachycardic but normoxic. Imaging revealed near-complete collapse of the left lung and mediastinal shift. Emergent thoracentesis removed 2.1 liters of red-yellow fluid; analysis revealed an exudative effusion with markedly elevated amylase levels. Cultures and cytology were negative. Non-contrast CT of the thorax demonstrated fibrotic changes and traction bronchiectasis in LLL. Repeat abdominal CT and MRI/MRCP demonstrated normal pancreatic and biliary anatomy without pseudocyst or identifiable fistulous tract. Despite this, pleural effusion reaccumulated and evolved into a loculated hydropneumothorax with lung entrapment. Clinical picture and persistent amylase-rich fluid raised concern for occult pancreatic leak and possible pancreatic enzyme translocation from the abdomen. On hospital day 9, the patient underwent VATS with decortication. Pathology confirmed chronic empyema with fibrinous pleural peel and no malignancy. Postoperatively, the patient remained on room air with improving lung expansion. Chest tube output was minimal and repeat imaging showed improved aeration. He was discharged with a LAMA inhaler, incentive spirometer, and GI-directed management including octreotide and pancreatic enzymes. Discussion This case highlights the diagnostic limitations in evaluating ARPE without radiographic fistula or pseudocyst visible. While MRCP is the preferred modality to identify PPFs6, fistulas may be small, intermittent, or obscured7. High suspicion is warranted in patients with elevated pleural fluid amylase and a history of pancreatitis. ARPE may originate from occult pancreatic leaks even in absence of imaging evidence. The patient’s progression to chronic empyema and lung entrapment necessitated VATS, underscoring the role of early surgical consultation when conservative measures fail8,9. As cytology and histology excluded malignancy, surgical decortication was ultimately diagnostic and therapeutic. Ultimately, the patient had minimal recurrence after achieving pancreatic control through dietary and lifestyle modifications alongside pancreatic enzyme supplementation, suggesting that addressing the underlying pancreatic pathology remains a cornerstone of long-term management. This abstract is funded by: None
Obeid et al. (Fri,) studied this question.