C52-18 Amylase Rich Pleural Fluid: A Diagnostic Clue to Esophageal Perforation

Abstract Introduction Amylase-rich pleural effusions are uncommon, and when present are typically associated with pancreatic disease or malignancy. Esophageal perforation is a rare and life-threatening cause of amylase rich effusions. Diagnosis is frequently delayed because the presentation often mimics more benign conditions, leading to high morbidity and mortality. We present a case of amylase-rich pleural effusion secondary to esophageal perforation. Case A 65-year-old woman with alcohol use disorder, hypertension, tobacco use, and prior deep-vein thrombosis presented with acute epigastric pain, nausea, and vomiting. Vitals signs included HR 182 beats per minute, BP 102/82 mmHg, and normal temperature. Physical exam revealed epigastric tenderness and decreased breath sounds over the right lower lung field.Laboratory findings revealed leukocytosis and severe lactic acidosis. CT chest/abdomen/pelvis demonstrated a right hydro-pneumothorax. The patient developed septic shock requiring vasopressors and ICU admission. Antibiotic treatment included Pipcillin/tazobactam and Vancomycin. A chest tube was placed, which drained 950 mL of purulent fluid. Pleural fluid analysis revealed pH 6.8, LDH 888 U/L, protein 3 g/dL, triglycerides 48 mg/dL, and amylase 2526 U/L.Flexible bronchoscopy revealed copious bilious secretions throughout both lungs. Subsequent endoscopy revealed a punctate perforation just proximal to the lower esophageal sphincter. An esophagram demonstrated contrast dye migrating into the pleural space. An esophageal stent was placed. The patient was liberated from the ventilator after clinical stabilization but remained with persistent empyema. Despite aggressive management, she suffered recurrent respiratory failure, was transitioned to comfort care, and expired on hospital day 8. Discussion This case highlights the diagnostic challenge of identifying esophageal perforation in critically ill patients presenting with amylase-rich pleural effusion. The markedly elevated pleural amylase with normal serum enzymes suggests salivary-type amylase leakage through an esophageal defect. Early recognition is crucial, as mortality rises sharply beyond 24 hours of perforation. Clinicians should maintain high suspicion for this entity in patients with vomiting, chest pain, or unexplained empyema. Prompt drainage, stenting or surgical repair, and sepsis control remain cornerstones of management. This abstract is funded by: none