Pancreaticopleural fistula presenting as respiratory distress in previously healthy adolescent
American Journal of the Medical Sciences
; 365(Supplement 1):S300, 2023.
Article
in English
| EMBASE | ID: covidwho-2236920
ABSTRACT
Case Report Respiratory distress is one of the most common complaints evaluated by pediatric providers in the office and emergency department setting. While primary cardiopulmonary processes represent the majority of cases of respiratory distress, pleural effusions of extravascular origin remain a rare but important differential. In this case, we present a previously healthy adolescent female who presented to our institution with respiratory distress and was subsequently found to have a pancreatic pleural effusion in the setting of a pancreaticopleural fistula. A 13 year old female with no chronic past medical history presented to the emergency department for three weeks of progressively worsening shortness of breath. History was notable for SARS-CoV-2 infection 6 months prior and intermittent night sweats and fevers for previous 4 weeks. She denied trauma, abdominal pain, nausea, vomiting, diarrhea, or anorexia. Her exam was notable for tachycardia, tachypnea, tripod positioning and absent breath sounds on her left. Chest computed tomography (CT) revealed left pleural effusion of entire left hemithorax with midline shift in addition to right sided pulmonary thromboembolism, small right sided pleural effusion and venous thromboses of the left internal jugular, subclavian, and proximal innominate veins. A left thoracentesis was performed, and patient was admitted to the PICU on a heparin infusion with subsequent left chest tube placement. Follow-up CT imaging revealed bilateral renal infarcts, iliac vein thrombosis, and a pancreatic fluid collection extending into the mediastinum with pancreatic ductal dilation. Magnetic resonance cholangiopancreatography further characterized the pancreatic lesion as a cystic tract traversing from the inferior mediastinum into the retroperitoneum and replacing the majority of the pancreatic gland suggesting a pancreaticopleural fistula as the source of a pancreatic pleural effusion. Serum amylase was 256 U/L and serum lipase was 575 U/L. Pleural fluid amylase was 1702 U/L and pleural fluid lipase was >2400 U/L, exceeding detection limit of this institution's lab. An extensive diagnostic work-up included infectious, hematologic, oncologic, autoimmune and rheumatologic etiologies and was largely unremarkable. Given concern for pancreaticopleural fistula, patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which was diagnostic for pancreatic divisum. A pancreatic duct stent was placed with normalization of serumpancreatic enzymes prior to discharge and resolution of pleural effusion at one month post ERCP Although an initial episode of acute pancreatitis usually resolves with supportive care, this case is a reminder that pancreatitis can present with local and systemic complications including pulmonary effusion or venous thromboses and keeping a high index of suspicionfor it is crucial toavoid delaying diagnosis and care. Copyright © 2023 Southern Society for Clinical Investigation.
abdominal pain; abnormal respiratory sound; acute pancreatitis; adolescent; amylase blood level; anorexia; brachiocephalic vein; case report; chest tube; clinical article; complication; computer assisted tomography; conference abstract; coronavirus disease 2019; diarrhea; dyspnea; emergency ward; endoscopic retrograde cholangiopancreatography; female; fever; fistula; follow up; human; human tissue; injury; kidney infarction; limit of detection; lung embolism; magnetic resonance cholangiopancreatography; mediastinum; medical history; nausea and vomiting; night sweat; pancreas divisum; pancreas juice; pancreatic duct stent; pancreatic pleural effusion; pancreatitis; pleura effusion; respiratory distress; retroperitoneum; surgery; tachycardia; tachypnea; thoracocentesis; thrombosis; triacylglycerol lipase blood level; vein thrombosis; amylase; endogenous compound; heparin; triacylglycerol lipase
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Database:
EMBASE
Type of study:
Cohort study
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Diagnostic study
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Etiology study
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Experimental Studies
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Prognostic study
Language:
English
Journal:
American Journal of the Medical Sciences
Year:
2023
Document Type:
Article
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