Black pleural eﬀusion B Jayakrishnan, Babar Dildar, Dawar M Rizavi, Saif M Al Mubaihsi, Adil Al Kindi
A 56-year-old man undergoing treatment for a prostatic acinar adenocarcinoma was referred to us in May, 2014, for assessment of a massive right pleural eﬀusion (ﬁgure). Although the eﬀusion was large, he had only mild shortness of breath and was admitted originally for urinary incontinence. A pleural aspiration showed black pleural ﬂuid (ﬁgure). This ﬂuid was determined to be an exudate with very high concentrations of protein (85 g/L; serum protein 56 g/L), lactate dehydrogenase, and amylase. We drained about 3 L of this black pleural ﬂuid from the patient over the following 24 h. Fibreoptic bronchoscopy was normal. However, a thoracoscopy showed nodularity of the visceral and parietal pleura with signiﬁcant pleural thickening. Pleural ﬂuid cytology showed groups of neoplastic cells arranged in balls, gland, and papillioid conﬁguration in a haemorrhagic background with mesothelial cells and mixed population of inﬂammatory cells. Immunohistochemistry studies favoured a diagnosis of an adenocarcinoma of pulmonary origin. Percutaneous and thoracoscopic pleural biopsies also conﬁrmed this diagnosis. The patient is receiving treatment for lung and prostate cancer and at last follow-up in February, 2015, he had poor performance status and the pleural eﬀusion was persisting. A
Black pleural eﬀusions are extremely rare and have been reported previously in patients with pleural infections caused by Aspergillus niger and Rhizopus oryzae, metastatic melanoma, adenocarcinoma of the lung, pancreaticopleural ﬁstula, oesophageal perforation during activated charcoal treatment for a drug overdose, and in patients actively using crack cocaine. The black pleural ﬂuid in our patient was most likely due to haemolysis and the presence of haemosiderinladen macrophages after a massive bleed into the pleura. The absence of clinically signiﬁcant symptoms in spite of the massive eﬀusion and the fact that the ﬂuid was black and not red suggest that the ﬂuid collected over a prolonged period of time and that the bleeding would have occurred a long time before presentation. Increased concentrations of amylase in the pleural ﬂuid, as noted in our patient, are commonly seen in patients with lung cancer—most frequently in those with adenocarcinomas.
Published Online March 6, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62003-1 Department of Medicine (B Jayakrishnan FRCP, B Dildar FCPS, D M Rizavi MRCP, S M Al Mubaihsi FRCP[C]) and Department of Surgery (A Al Kindi FRCSC), Sultan Qaboos University Hospital, Muscat, Oman Correspondence to: Dr B Jayakrishnan, Department of Medicine, Sultan Qaboos University Hospital, PO Box 35, PC 123, Muscat, Oman [email protected]
Contributors BJ, BD, DR, and SAM cared for the patient and AAK did the surgical intervention. All authors contributed to the writing of the report. Written consent to publication was obtained.
Figure: Chest radiograph of the massive right pleural eﬀusion (A) and black pleural ﬂuid (B)
www.thelancet.com Published online March 6, 2015 http://dx.doi.org/10.1016/S0140-6736(14)62003-1