Three cases of black pleural effusion.

Our third patient was a 43-year-old female with known ansa pancreatica with consequent recurrent acute pancreatitis, chronic pain syndrome, chronic obstructive pulmonary disease, and gastroenteric reflux disease, who presented to an outside facility with acute onset of cough, myalgia, malaise, and progressive dyspnea and orthopnea. Upon evaluation in the emergency department, point-of-care ultrasound revealed a right-sided fluid collection. Right-sided thoracentesis was performed, yielding black pleural fluid. She was notably hypoxemic, requiring 6 L of oxygen by nasal cannula and hypotensive on vasopressors. She was transferred to our hospital for further management. Notably, 3 weeks prior to admission, the patient had an episode of acute pancreatitis. She underwent ERCP which revealed benign biliary papillary stenosis and choledocholithiasis. Biliary and pancreatic duct stents were placed, pancreatic and biliary sphincterotomies were also done. On that admission, she was incidentally found to have transudative right-sided pleural effusion felt to be due to pancreatic pseudocyst. This was managed with a temporary chest tube placement. She was eventually discharged home with supplemental oxygen. Upon readmission to our hospital, a right-sided pigtail chest tube was inserted. 750mL of black pleural effusion was drained ( Fig. 1 -C). The aspirated fluid later grew E.coli, consistent with empyema ( Table 1 ). Other significant findings include leukocytosis with left shift, normal electrolytes and renal function, hypoalbuminemia, mildly elevated alkaline phosphatase, serum amylase 284 U/L, serum lipase 85 U/L, otherwise normal liver function tests, and negative blood cultures. CT imaging showed sequelae of prior acute pancreatitis with thin tract between a small pancreatic pseudocyst and a rim-enhancing fluid collection adjacent to the esophagus. Fistulation was suspected to the pleural space, consistent with pancreaticopleural fistula. A biliary duct stent was confirmed to be in place ( Fig. 4 ). Fig. 4 (Top left and right) Axial and sagittal cut of CT chest with contrast showing a rim-enhancing fluid collection in the right lower lobe with a chest tube in the space. There is an adjacent rim-enhancing fluid collection along the medial aspect of the pleura adjacent to and running along the posterior mediastinum and esophagus, which terminates at the level of the diaphragmatic hiatus. This is suspected to be a fistula. (Bottom left) ERCP with cannulation of the pancreatic duct. After contrast injection, extravasation of contrast is seen from the pancreatic tail. Fig. 4 (Top left and right) Axial and sagittal cut of CT chest with contrast showing a rim-enhancing fluid collection in the right lower lobe with a chest tube in the space. There is an adjacent rim-enhancing fluid collection along the medial aspect of the pleura adjacent to and running along the posterior mediastinum and esophagus, which terminates at the level of the diaphragmatic hiatus. This is suspected to be a fistula. (Bottom left) ERCP with cannulation of the pancreatic duct. After contrast injection, extravasation of contrast is seen from the pancreatic tail. The patient was treated with antibiotics, and gastroenterology consultation was obtained. After multi-disciplinary discussion, it was decided to insert a left-sided pigtail chest tube. By contrast, the left-sided fluid was yellow, serous, and hazy. Fluid analysis was consistent with a simple parapneumonic effusion ( Table 1 ). ERCP was performed with sludge removal, pancreatic duct stent placement, and common bile duct stent placement. She completed her course of antibiotics, and chest tubes were removed. She was discharged home in a stable condition with a 4-week course of IV Ceftriaxone.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Black pigmentation is a highly unusual but distinctive finding in patients with effusions, and the distinctive color helps to narrow the differential. There are multiple causes for BPE, including pancreatic pseudocyst-formation with resulting fistulation into the pleura, and esophageal rupture as we have described in this case series and review of the literature. Recognition of potential differentials will aid in directing further investigations and therapy towards the underlying cause. Overall outcomes are favorable for BPE when related to pancreatic pseudocyst (often requiring a significant number of interventions) but are poor when associated with metastatic melanoma.

Pleural effusions are common with an estimated incidence of greater than 1.5 million cases per year. The most common etiologies are congestive heart failure, pneumonia, and cancer. Determining the underlying cause is imperative for appropriate treatment of the effusion, ensuring appropriate resolution and/or management of the fluid [ 2 ]. BPE is infrequently reported in the literature. Etiologies identified in literature to date include infections, pancreatic pseudocysts with pancreaticopleural fistula, metastatic melanoma, hemorrhage due to lung cancer, charcoal aspiration, teratomas, autoimmune conditions, and crack cocaine use [ Table 2 ]. Table 2 Black pleural effusions cases (A-LL). Table 2 Author Age/Sex Diagnosis Management Outcome Watanabe et al. [ 10 ] 57/M Pancreaticopleural fistula; Acute on chronic alcoholic pancreatitis Tube thoracostomy Effusion resolved Ye, J. et al. [ 11 ] 64/M Pancreaticopleural fistula; Suspected IgG4 Disease Thoracentesis; Endoscopic pancreatic duct stenting Effusion resolved Arumairaj, A.J. et al. [ 12 ] 48/M Pancreatic pleural effusion Tube thoracostomy Effusion resolved Miyadera, K. et al. [ 13 ] 59/F Pancreaticopleural fistula/Autoimmune pancreatitis Endoscopic pancreatic sphincterotomy and pancreatic duct stent placement/Systemic steroids Effusion resolved Nikiforov et al. [ 14 ] 27/M Severe acute pancreatitis Tube thoracostomy Effusion resolved Tanaka, T. et al. [ 15 ] 55/M Boerhaave syndrome Thoracentesis; Surgical repair Effusion resolved Jagganath et al. [ 16 ] 24/M Pancreaticopleural fistula; Pancreatic pseudocyst Tube thoracostomy, somatostatin analogue; Open cystogastrostomy Effusion resolved Newman et al. [ 17 ] 34/M Crack cocaine Thoracentesis Unknown Ng, Z. et al. [ 18 ] 80/F Metastatic adenocarcinoma with indeterminate primary; Complicated by intrapleural hemorrhage Thoracentesis Effusion resolved Yousaf, Z. et al. [ 19 ] 71/M Metastatic adenocarcinoma with indeterminate primary Thoracentesis; Tube thoracostomy; Wedge resection Death Ishigaki, S. et al. [ 20 ] 54/F Pancreaticopleural fistula/Pancreatic pleural effusion Thoracic and endoscopic pancreatic duct drainage Effusion resolved Sumalani et al. [ 21 ] 49/M Metastatic melanoma Thoracentesis Death Fernandez et al. [ 22 ] 86/M Metastatic adenocarcinoma of the lung Thoracentesis Death Hirsche et al. [ 23 ] 65/F Boerhaave Syndrome Tube thoracostomy; Operative repair of esophageal rupture Effusion resolved Mansour et al. [ 24 ] 38/F Thoracic endometriosis Thoracentesis; VATS with pleurectomy; Hormonal therapy Effusion resolved Mitra et al. [ 25 ] 35/F Mediastinal cystic teratoma Exploratory thoracotomy; Surgical excision of mediastinal teratoma Effusion resolved Guo, F. et al. [ 26 ] 14/F Pancreatic pseudocyst Thoracentesis; Surgical internal jejunal drainage Effusion resolved Patel, G. et al. [ 27 ] 63/M Metastatic melanoma Tube thoracostomy; Chemical pleurodesis Effusion resolved; Transitioned to palliative care Hirosawa et al. [ 28 ] 58/M Pancreaticopleural fistula; Pancreatic pseudocyst Tube thoracostomy; ERCP; Endoscopic nasopancreatic drainage Effusion resolved; Death due to unrelated cause Mishe'el, S. et al. [ 29 ] 77/M Metastatic melanoma Thoracentesis Death Thampy, E. et al. [ 30 ] 58/F Metastatic mucinous adenocarcinoma of the lung complicated by intrapleural hemorrhage Thoracentesis; Palliative chemotherapy Persistent pleural effusion; Indwelling pleural catheter placement Chhabra, A. et al. [ 31 ] 74/M Metastatic melanoma Bedside ultrasound-guided thoracentesis Effusion resolved Jayakrishnan, B. et al. [ 32 ] 56/M Metastatic pulmonary adenocarcinoma complicated by massive pleural bleeding Thoracentesis; Medical treatment for lung and prostate cancer Persistent pleural effusion George et al. [ 33 ] 38/M Rheumatoid pleurisy Thoracentesis; Low dose prednisone therapy Effusion resolved Kaur et al. [ 34 ] 37/F Pancreaticopleural fistula; Pancreatic pseudocyst Tube thoracostomy, ERCP-guided pancreatic duct stent placement Effusion resolved Mookherjee et al. [ 35 ] 37/F Pancreaticopleural fistula; Pancreatic pseudocyst Tube thoracostomy; ERCP with pancreatic dust stenting Effusion resolved Huang et al. [ 36 ] 47/M Pancreaticopleural fistula; Pancreatic pseudocyst Thoracentesis Death Makino et al. [ 37 ] 39/M Pancreaticopleural fistula; Pancreatic pseudocyst Tube thoracostomy; Endoscopic nasopancreatic drainage Effusion resolved Koide et al. [ 38 ] 54/M Pancreaticopleural fistula Thoracentesis Effusion resolved Liao, W–C. et al. [ 39 ] 71/M Metastatic melanoma Tube thoracostomy Effusion resolved; Further treatment declined Mohan, K.M. et al. [ 40 ] 35/M Metastatic melanoma Tube thoracostomy followed by chemical pleurodesis Recurrence of fluid; Lost to follow-up Pantanowitz et al. [ 41 ] 88/M Postoperative sympathetic pleural effusion; Crack cocaine Thoracentesis Unknown 46/M Parapneumonic pleural effusion; Crack cocaine Thoracentesis Unknown Rojas-Solano, J.F. et al. [ 42 ] 89/M Metastatic adenocarcinoma of the lung complicated by intrapleural hemorrhage Thoracentesis; Pleural biopsy Effusion resolved; Transitioned to Palliative Care Lai, C–C. et al. [ 43 ] 46/M Rhizopus oryzae empyema; History of acute myelogenous leukemia s/p allogeneic bone marrow transplant Thoracentesis, antibiotics Death Singh, B. et al. [ 44 ] 34/M Crack cocaine Thoracentesis, pleural biopsy Unknown 45/M Crack cocaine Thoracentesis Unknown Unknown Crack and tobacco smokers; Primary pulmonary adenocarcinoma Thoracentesis Unknown Unknown Crack and tobacco smokers; Metastatic melanoma Thoracentesis Unknown Kimmerling, E.A. et al. [ 45 ] 64/M Invasive Aspergillosis secondary to A. niger infection Intravenous antibiotics; bronchoscopically guided intracavitary antibiotics Death Justiniani, F. et al. [ 46 ] 25/M Activated charcoal aspiration; Esophageal rupture Tube thoracostomy; Antibiotics Effusion resolved Metzger. et al. [ 47 ] 63/M Aspergillus niger infection; bacterial superinfection Tube thoracostomy; Antibiotics; Right upper lobe lobectomy Effusion resolved Black pleural effusions cases (A-LL). When encountering BPE in practice, the provider should combine thorough history-taking with pleural fluid analysis to determine the etiology. While BPE is a rare discovery, there are a limited number of etiologies in the differential diagnosis. The European Respiratory Society published an interactive case highlighting the sequential thought process and management of a patient with BPE [ 3 ]. When the history is non-specific or multiple causes of the dark effusion are plausible, diagnostic tests are necessary. Beyond the usual studies included in Light criteria [ 5 ], black pleural fluid should be tested for pancreatic enzyme levels, amylase, cytopathology, and bacterial and fungal cultures. A prior case series proposed mechanisms for the formation of black pleural effusion; these mechanisms can be broadly categorized into two major groups [ 4 ]. The first is the presence of black-pigmented material in the effusion, such as in A. niger empyema where the spores are known to be black in color, cytoplasmic melanin in melanoma cells, and aspiration of charcoal slurry. The second group is local inflammation, usually due to irritating substances such as pancreatic enzymes or blood with consequent liquefactive necrosis. All three of our patients likely fall into the latter category. Case 2 had a viscus perforation with infiltration of intestinal material and blood into the abdomen and then into the mediastinum. The presence of Candida and bacteria in the pleural fluid supports this assumption [ 6 ]. C. glabrata is known to be part of normal endogenous flora. Where it was previously thought to be a nonpathogenic entity, it has since been documented to be associated with high rates of mortality when seen in immunocompromised patients [ 7 ]. Candida empyema in general is relatively rare but has been reported in cases of esophageal or gastric rupture [ 6 ]. There are presently no randomized trials to guide the optimal approach to treating Candida empyema, and mortality can be as high as 54% despite appropriate therapy [ 6 ]. Case 1 and 3 both suffered from chronic pancreatitis, complicated by pancreatic pseudocysts with spillage of peripancreatic fluid and enzymes into the pleural space, which represent the most reported cause for BPE. Of patients with chronic pancreatitis, 4.5% go on to develop pleural effusion [ 8 ]. Pleural effusion-formation in the setting of pseudocysts has been proposed by Saraya et al. [ 4 ] to form through anterior or posterior extension of the pseudocyst. Anterior disruption into the peritoneal cavity results in pancreatic ascites; posterior disruption causes a retroperitoneal fistula into the pelvis or superiorly through the esophageal or aortic hiatus. Finally, there may also be direct penetration through the dome of the diaphragm, such as in our case. Endoscopic treatment of pancreatic pseudocysts is effective, with a 94% initial success rate and 90% cyst resolution rate. Approximately 16% of cases have cyst recurrence. Alternative strategies include surgery or percutaneous drainage [ 9 ]. In our review of the literature, 38 unique cases were found and are summarized ( Table 2 ). The most common etiology was related to pancreaticopleural fistula or pancreatitis-related effusions (n = 15), followed very closely by neoplasia (n = 12). Using the approach to the cases as described by Saraya, as discussed above, most reported cases were within the second group of black effusion caused by liquefaction and necrosis (n = 30), with the remainder falling under the first group and consisting of a variety of black-pigmented materials (eg, crack cocaine-related charcoal pigment, charcoal slurry, A. niger spores). Most cases required additional interventions including surgery, endoscopic intervention, and medical management. While BPE tended to respond favorably to intervention, 9 cases resulted in mortality or transition to hospice care. All but 2 of these cases were related to metastatic malignancy. Other types of black effusions exist within the human body. Most commonly, black ascites is associated with similar etiologies as described above for black pleural effusions with additional causes of ovarian cancer and leakage of fecal matter [ 48 , 49 ]. Black or very dark colored urine is uncommon, but the differential includes metastatic melanoma, alkaptonuria, porphyria and rhabdomyolysis [ 50 ]. Melanuria, or melanoma present in the urine, turns black after it has been exposed to the air due to oxidization and can be useful for diagnosing metastatic melanoma [ 51 ]. Rarely, black fluid has been associated with post operative fungal infections [ 52 ]. Black fluid from bronchoalveolar lavage samples during bronchoscopy of the lungs has also been reported; the causes are vast including copious carbon-laden macrophages from cigarette and synthetic marijuana [ 53 , 54 ]. There have also been case reports of black joint effusions from onchronosis secondary to alkaptonuria and melanosis from metal-on-metal joint replacements causing dark synovial fluid and synovium [ 55 , 56 ]. Overall, these effusions follow a similar suspected pathway to that of black pleural effusion with most caused by necrosis or pigment related effusions.

Black pleural effusions (BPE) are extremely rare, exudative pleural effusions that have a characteristic black appearance. On presentation, BPE will resemble the symptoms of any other pleural effusion: dyspnea, cough, and pleuritic chest pain [ 1 ]. Given its striking appearance, visualization of it should immediately call to mind a handful of distinctive differential diagnoses. Herein we describe three consecutive cases of black pleural effusion managed at our institution. We subsequently describe the current literature on this entity, including a summary of all reported cases that we were able to find to date.

None.