Prepared by Suresh Ramamurthy, MD, Internal Medicine Resident, Vijay P. Balasubramanian, MD, Pulmonary &
Critical Care Fellow, Hong Yung Choi, MD, Professor, Department of Pathology, and William O'Neill, MD,
Assistant Professor, Division of Pulmonary & Critical Care, Department of Medicine, Clement A. Zablocki VA
Medical Center and Medical College of Wisconsin, Milwaukee, Wis
A 47-year-old man presented with complaints of acute abdominal pain radiating to the right flank, fever, chills, night sweats, and anorexia. His history included alcoholism, chronic pancreatitis, and diabetes. Examination and testing revealed: decreased breath sounds in the right lung base and right upperquadrant tenderness; elevated white blood cell count (21.8 x 109/L) with left shift; elevated alkaline phosphatase (304 U/L). Chest x-ray showed a small right pleural effusion. Computed tomography (CT) scan showed a large fluid collection in the right lobe of the liver and a small loculated right pleural effusion (Figure 1), with exudative pleural fluid. CT-guided drainage of the fluid collection with a pigtail catheter revealed dark red fluid and necrotic tissue; 12 hours postprocedure he experienced increasing dyspnea and right pleuritic chest pain. Repeat chest x-ray demonstrated a massive right pleural effusion (Figure 2). A right thoracotomy with pleural drainage and decortication revealed the diagnosis (Figure 3).
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