Abstract Introduction Pleural effusion results from fluid accumulation in the pleural space and may arise from diverse etiologies. Light’s criteria and gross fluid characteristics assist in identifying the underlying cause. Among rare presentations, black pleural effusion is an unusual finding most commonly linked to malignancy or pancreatopleural fistula (PPF), a complication typically seen in chronic pancreatitis. We report a case of recurrent bilateral pancreatic pleural effusion refractory to conservative therapy and successfully managed with endoscopic decompression. Case Presentation A 69-year-old woman with a history of chronic alcoholic pancreatitis presented with progressive dyspnea. Computed tomography (CT) of the chest revealed a large loculated left pleural effusion with near-complete hemithorax opacification and a moderate right-sided effusion. A necrotic fluid collection was visualized at the posterior pancreatic body. A left chest tube drained black pleural fluid. Laboratory analysis demonstrated a neutrophil-predominant exudate with markedly elevated lipase (6000 units per liter U/L) and amylase (7838 U/L), normal pH and glucose levels, and negative cytology and microbiology. Conservative management, including chest tube drainage and supportive therapy, was initiated, but the effusion recurred. The patient was started on octreotide and subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP). Although no fistula was directly visualized, narrowing of both the pancreatic and common bile ducts was observed, and biliary and pancreatic stents were placed. Pleural output decreased significantly following ERCP, the chest tube was removed, and follow-up imaging confirmed resolution. Discussion Black pleural effusions are rare and have been associated with malignancy, PPF, and fungal infections such as Aspergillus niger and Rhizopus oryzae. PPF arises secondary to pancreatic ductal disruption or pseudocyst extension, most often in chronic alcoholic pancreatitis. The reported incidence is approximately 0.4% in chronic pancreatitis and 4.5% in cases with pancreatic pseudocysts. Diagnosis requires a high suspicion supported by imaging with CT or magnetic resonance cholangiopancreatography (MRCP) and pleural fluid analysis, with markedly elevated amylase levels serving as a key diagnostic clue. Conservative management alone has limited success (∼16%), while endoscopic therapy achieves higher success rates (up to 79%). Surgical intervention, although the most definitive (∼94% success), is reserved for refractory cases. Conclusion This case highlights the diagnostic complexity of pancreatic pleural effusion and the pivotal role of ERCP with ductal stenting, even in the absence of a visualized fistula. Early recognition and timely endoscopic intervention can prevent recurrence and avoid surgical morbidity. Figure 1: Coronal chest CT scan demonstrating a large left pleural effusion causing near-complete collapse of the left lung This abstract is funded by: None
Martini et al. (Fri,) studied this question.