Gastropleural fistula masquerading as chylothorax in a child with lymphoma

Abstract

We report the case of an 8-year-old boy with diffuse large B cell lymphoma who developed a right-sided spontaneous pneumothorax with pleural effusion after recovery from septic shock. The pleural fluid was thought to be malignancy-associated chylothorax concomitant with complicated pleural effusion due to a milky-like appearance, a high level of triglycerides and Gram-negative bacteria staining in the fluid. He was put on total parental nutrition and octreotide for 2 weeks, but did not improve. The laboratory results also showed a persistent bacterial infection in the pleural fluid despite appropriate antibiotics. Eventually, a CT scan revealed a fistulous tract between the right pleural cavity and the stomach. Fistula repair was successful by right open thoracotomy with decortication. Even though the gastropleural fistula is a very rare condition in paediatric patients, the physician should consider this diagnosis in a patient who has an unusual presentation or refractory chylothorax-like pleural effusion.

Keywords: empyema; paediatric oncology; pleural infection; pneumothorax.

Figure 1

CT of the chest including abdomen showing many matted lymph nodes located at the mediastinum, paraoesophagus, oesophagogastric junction and upper part of the stomach.

Figure 2

CT of the chest including abdomen comparing previous matted nodes before commencing chemotherapy (A–C) and a fistulous tract between the stomach and the right pleural cavity causing a large right hydropneumothorax with empyema-like features (D–F) in transverse plane.

Figure 3

Oesophagogastroduodenoscopy demonstrating the fistulous tract at the oesophagogastric junction (arrow).