What question did this study set out to answer?

To report a rare case of dual fungal infections causing bilothorax and peritonitis in a patient without prior biliary intervention.

May 20, 2026

B72-45 Fungal Empyema Masquerading as Bilothorax With Concurrent Fungal Peritonitis: A Rare Dual-candida Infection

Key Points

To report a rare case of dual fungal infections causing bilothorax and peritonitis in a patient without prior biliary intervention.
Case presentation of a 37-year-old man with pulmonary tuberculosis and rectal adenocarcinoma.
Diagnosis based on pleural fluid analysis, including bilirubin ratio and cultures confirming fungal infections.
Treatment involved exploratory laparotomy, drainage, and fluconazole therapy.
Diagnosis confirmed bilothorax with a pleural fluid-to-serum bilirubin ratio of 11.75.
Cultures yielded Candida parapsilosis from pleural fluid and Candida tropicalis from peritoneal fluid.
Successful clinical recovery achieved with timely fluconazole treatment and surgical intervention.

Abstract

Abstract Introduction Bilothorax, or the presence of bile in the pleural space, is a rare cause of exudative effusion usually linked to hepatobiliary injury or intervention. Secondary fungal infection is exceedingly uncommon and carries high mortality. We describe a unique case of bilothorax complicated by both fungal empyema and fungal peritonitis caused by distinct Candida species, occurring without prior biliary instrumentation. Case Presentation A 37-year-old man with bacteriologically confirmed pulmonary tuberculosis and rectal adenocarcinoma presented with fever, cough, and a progressive perianal mass. Following incision and drainage with diverting colostomy, he developed abdominal distension, peritonitis, and respiratory distress requiring intubation. Imaging revealed ascites and bilateral pleural effusions. Thoracentesis drained dark greenish-brown fluid with a pleural fluid bilirubin of 39.8 mg/dL versus serum bilirubin of 3.35 mg/dL (ratio = 11.75), confirming bilothorax. Pleural fluid culture yielded Candida parapsilosis, consistent with fungal empyema. Peritoneal fluid cultures grew Candida tropicalis, confirming concurrent fungal peritonitis. Exploratory laparotomy demonstrated bowel perforation with bilious ascites. Bilateral drainage, surgical repair, and fluconazole therapy led to clinical recovery and discharge. Discussion Among reported cases of bilothorax, over 80% are iatrogenic, with fungal superinfection documented only in isolated reports. The 2024 case by Park et al. described C. parapsilosis empyema following biliary drainage; in contrast, our patient presented spontaneously with two distinct Candida species isolated from pleural and peritoneal cavities. The proposed mechanism involves bile leakage secondary to bowel perforation, followed by transdiaphragmatic migration of infected bilious ascites. Diagnosis rests on a pleural fluid-to-serum bilirubin ratio 1. Fungal empyema is associated with mortality up to 70%, emphasizing the importance of early recognition, microbiologic confirmation, drainage, and antifungal therapy. Our case highlights that timely fluconazole therapy with adequate source control can achieve full recovery, even in critically ill patients with multiple comorbidities. Conclusion This is the first reported case of bilothorax complicated by both fungal empyema (C. parapsilosis) and fungal peritonitis (C. tropicalis) without prior hepatobiliary intervention. Early identification of bilothorax through pleural bilirubin analysis, coupled with prompt drainage and targeted antifungal therapy, is crucial for survival. This case expands the clinical spectrum of fungal bilothorax and underscores the need for heightened awareness of fungal superinfection in complex intra-abdominal disease. This abstract is funded by: None

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