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Massive pleural effusion
  1. A Salih
  1. Department of General Surgery, Queen Mary's Hospital, Sidcup, Kent, UK
  1. Mr A Salih, Headley Atkins, 8th Floor, New Guy's House, Guy's Hospital, St Thomas Street, London SE1 9RT, UKalisalih{at}aol.com

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A 50 year old alcoholic male patient, with a known history of chronic pancreatitis and insulin dependent diabetes but no past history of respiratory problems, presented with progressive shortness of breath for a duration of three months and epigastric discomfort for two days before admission.

On examination he was pyrexial, dyspnoeic, and tachypnoeic with dullness and reduced air entry of the left chest. The abdomen was soft, with slight epigastric tenderness on deep palpation.

His white cell count was 23.5 × 109/l. Serum amylase was 2500 IU/l, serum bilirubin 81 μmol/l, and alkaline phosphatase 1242 IU/l. Pleural aspiration yielded a bloodstained exudative fluid with a protein concentration of 56 g/l.

Chest radiography revealed left sided massive pleural effusion (fig 1). Computed tomography demonstrated pancreatic ductal and parenchymal calcification (fig 2). Previous computed tomography performed a year before revealed a pseudocyst arising from the head of pancreas, adjacent to the left lobe of the liver (fig 3). The cyst had settled with conservative management.

Figure 1

Chest radiography showing left sided massive pleural effusion.

Figure 2

Computed tomography showing pancreatic ductal and parenchymal calcification.  

Figure 3

Computed tomography performed a year earlier showing a pseudocyst.

Questions

(1)
What is the most probable cause for the massive pleural effusion?
(2)
How should the diagnosis be confirmed?
(3)
What would be the differential diagnosis?
(4)
What are the options for treatment?

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