A black pleural effusion

Black pleural effusions are rare, and are associated with cancers, pleural infection (namely fungal), and pancreatic leakage. A 78-year-old with known cardiac comorbidities presented with a large right pleural effusion, and symptoms of breathlessness and weight loss. A computed tomogram (CT) scan showed a large right multiloculated collection and an aspirate of black pleural fluid had negative cytology and grew Klebsiella pneumoniae. Due to the concern that this might represent a malignancy, a thoracoscopy was planned but the patient had to be admitted for cardiovascular instability, and a chest drain was inserted. The local multidisciplinary team (MDT) ruled that this was not a cancer, and a video-assisted thoracoscopic surgery (VATS) was performed for infection clearance. The pleura looked bland, but biopsies were taken, an indwelling pleural catheter (IPC) was inserted. Histology showed a pleural adenocarcinoma and systemic anticancer treatment has been started. Pleural fluid analysis could not be done as it was too dark for routine laboratory analysis which is based on transparency to different wavelengths of light. The cytology was negative, which is not uncommon in patients with lung cancer, and the CT scan was reported as no cancer, again, which is not uncommon. Empyema and concurrent lung cancer is rare. Clinical suspicion was high, and clinicians should always pursue tissue biopsy if that is the case.