A rare case of pediatric pleural effusion: Pancreaticopleural fistula

To the Editor Dyspnea secondary to a pleural effusion is common in pediatrics. However massive pleural effusion secondary to pancreaticopleural fistula (PPF) is extremely rare in children. Since respiratory symptoms predominate diagnosis of PPF is challenging. Here we describe a case of PPF in a girl presented with dyspnea and massive pleural effusion who was successfully treated by endoscopic procedures after failed conservative therapy. An 8-year-old girl presented with intermittent cough for 4 weeks, exacerbated with dyspnea for 3 weeks. After she became dyspneic, a chest X-ray showed massive right pleural effusion (Figure 1A). Chest computed tomography (CT) confirmed a large right pleural effusion with atelectasis. She was admitted to local hospital and treated with thoracic tube drainage and anti-infection. On day 3 of local hospitalization, somatostatin, and parenteral nutrition were added because chronic pancreatitis was diagnosed by abdominal CT. During the next 2 weeks, her dyspnea and cough were improved. However, there was persistent effusion of hemothorax by chest tube. Then, the girl was referred to our hospital. Physical examination at admission revealed growth delay, thin, and having dullness to percussion with decreased breath sounds and vocal fremitus on the right hemithorax. Other aspects of the physical examinationwere unremarkable. Plasma amylase (252 IU/L) and lipase (134 IU/L) were both mildly elevated, whereas pleural fluid amylase was astronomical (46500 IU/L). Thoracicoabdominal CT revealed pancreatic calculi accompanied by dilatation of the main pancreatic duct and an abnormal tubular structure extending from the accessory pancreatic duct along the spine to the diaphragm horizon, considering