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
Tan et al. (Fri,) studied this question.