Abstract Introduction Bilothorax is a rare cause of pleural effusions that results from the introduction of bile into the pleural cavity secondary to trauma, iatrogenic interventions, or infections. While rare, prompt evaluation and treatment of a bilothorax is necessary to prevent further complications such as fibrothorax or empyema. Here we present a case of a bilothorax in an immunocompromised patient after percutaneous cholecystostomy tube placement. Case A 50-year-old male with history of poorly controlled HIV/AIDS (recent absolute CD4 count 8/cubic millimeter (cumm)), cryptococcal meningitis, and cholecystitis with recent percutaneous cholecystostomy tube replacement through a new tract, presents with two weeks of cough, night sweats, and unintentional weight loss. On arrival, he was afebrile, tachycardic to 120 beats/minute, normotensive, and saturating well on room air. Chest radiography demonstrated a persistent, known right hemidiaphragm. Chest computed tomography showed a small, right-sided pleural effusion with associated visceral and parietal pleural thickening. Initial differential diagnoses for the etiology of his pleural effusion remained broad given the patient’s immunocompromised state including opportunistic infections and malignancies such as Kaposi’s sarcoma and lymphoma. A thoracentesis was performed that withdrew orange pleural fluid with a cell count of 1357/cumm and 95% neutrophilic predominance. Pleural fluid analysis revealed: lactate dehydrogenase 4244 Units/Liter, protein 6.2 grams/deciliter (g/dL) (serum: 7.6 g/dL), cholesterol 116 milligrams/deciliter (mg/dL), glucose 10 mg/dL, and bilirubin 1.6 mg/dL (serum: 0.2 mg/dL)--consistent with an exudative effusion. His pleural to serum bilirubin ratio was 8 and subsequently diagnosed with a bilothorax. Pleural fluid cultures grew extended spectrum beta-lactamase producing Escherichia coli. The patient was started on meropenem and a computed tomography guided tube thoracostomy was placed to drain the empyema. He eventually underwent percutaneous cholecystostomy tube removal and cholecystectomy. Discussion The etiology of a new pleural effusion in an immunocompromised patient is extremely broad ranging from infections to malignancies. There should be high clinical suspicion for patients with recent percutaneous trans-hepatic biliary drainage as they may be at higher risk for developing a bilothorax. While there is no consensus on how to treat a bilothorax, rapid identification and treatment with tube thoracostomy and antibiotics are warranted as patients are at increased risk for empyema formation due to the favorability of bile for bacterial growth. While a tube thoracostomy may be used to treat a bilothorax, surgical intervention is usually warranted if a biliopleural fistula has formed. This abstract is funded by: None
Yu et al. (Fri,) studied this question.