Un singolare quadro di pleurite:il caso di Maddalena

Irritative pleurisy due to the presence of bile in the pleural cavity is a disease not frequently found. Here we describe a case of irritative pleurisy which arose in a 49-years old woman due to the passage of bile in the pleural cavity through a trans-diaphragmatic fistula. This case, clinically characterized by symptoms of fever with chills, cough and chest pain, came to our observation with the suspect of an infectious pleurisy. However an exploratory thoracentesis revealed a clear, citrine-colored pleural fluid which excluded a bacterial disease. Therefore, given the not infectious nature of the pleural effusion, we hypothesized a possible communication between the pleura and a large, simple, subdiaphragmatic hepatic cyst in the eighth segment (already known in history). In agreement with this hypothesis we measured bile acids in the pleural fluid that were present. An abdominal ultrasound showed no evident trans-diaphragmatic fistula but an hepatobiliary scintigraphy with Tc-99m TMBIDA showed the passage of contrast from bile ducts to the right pleural cavity. Moreover our hypothesis of irritative pleurisy was corroborated by the gradual regression of the febrile episodes, of chest pain, cough and improvement of gas exchange with systemic corticosteroid therapy. Three weeks after discharge, the patient repeated an abdominal ultrasound which finally showed a communication of 4 mm in diameter between the liver cyst and the pleural space. This is, to our knowledge, the first case of spontaneous bilio-pleural fistula reported in the literature.