S4435 A Rare Case of Black Pleural Effusion: Boerhaave Syndrome With Pulmonary Aspergillosis in Immunocompetent

Introduction: Black pleural effusion is a very rare condition with only a handful number of cases described in the literature. Causes include malignant melanoma, pancreaticopleural fistula with pseudocyst, lung adenocarcinoma and atypical fungal infections. We describe a case of a black pleural effusion that was positive for Aspergillus niger and enteric organisms following Boerhaave syndrome. Case Description/Methods: A 65-year-old man with past medical history significant for gastroesophageal reflux disease presented to the emergency department with sudden onset of shortness of breath, epigastric abdominal pain and intractable vomiting. He was working on his unfinished old basement for the past 2 years and has been experiencing some cough and congestion intermittently especially on the days he worked in the basement where he had noticed black mold before. In the emergency department, he was tachycardic and hypoxic requiring noninvasive pressure ventilation requiring admission to the intensive care unit. Labs include leukocytosis of 15,200/uL with predominant neutrophilia, but blood cultures were negative. Computerized tomography angiography of chest, abdomen and pelvis revealed a moderate to large right-sided pleural effusion with worsening pneumothorax requiring chest tube placement. Chest tube drained black colored pleural fluid. Voriconazole was added due to suspicion of a fungal infection. The following day, pleural fluid turned clear with cultures growing Enterococcus faecalis, Lactobacillus, Candida albicans and Aspergillus fumigatus. Pleural fluid studies suggested exudative effusion with elevated amylase level of 4281 U/L but negative for malignant cells. Repeat computed tomography chest abdomen with oral contrast revealed extravasation of oral contrast into the right pleural effusion consistent with gastroesophageal perforation near the posterior gastroesophageal junction. Subsequently, he underwent right thoracotomy and repair of esophageal perforation and decortication of right lung requiring intubation. Respiratory status improved and computed tomography confirmed no extravasation of contrast. Barium swallow study was negative for residual gastroesophageal leak. He was discharged on antibiotics with outpatient ID follow up. Discussion: This case aims to add to the existing literature and increase awareness of this rare condition with Boerhaave syndrome as an important differential diagnosis for black pleural effusion. Treatment of the underlying cause is crucial for a favorable outcome. Early diagnosis has improved outcomes through prompt initiation of treatment.