This case will further support the previously mentioned report of LIP associated with SLE.4 In cases of failed therapy with steroids or severe side effects, one may consider the use of MMF for further treatment. More research will be needed for fostering treatment guidelines in cases of LIP. All authors have no conflict of interest to disclose. “
“Pancreatico-pleural fistula (PPF) is a rare cause of recurrent, large

pleural effusions, usually resulting from chronic pancreatitis.1, 2, 3, 4 and 5 We report a unique case of successful resolution of PPF following endoscopic ultrasound (EUS)-guided therapy. A 58-year-old woman with a 30-pack-year smoking history and remote alcoholism presented with dyspnea due to large pleural effusions (Fig. 1). She Compound C in vitro had a remote history of abdominal pain but no current pain or diarrhea. Over a period of four months, she underwent 4 large-volume thoracenteses, 2 chest tube placements Ulixertinib in vivo and 2 thoracotomies for recurrent effusions; the etiology remained obscure until the 4th thoracentesis, when fluid amylase was measured and found to be markedly elevated (29,503 U/L). Chest radiography revealed pleural effusions. Magnetic resonance cholangio-pancreatography (MRCP) showed an irregular pancreatic

duct with non-visualization of the tail portion, and two small adjacent fluid collections (Fig. 2). A one-week trial of medical therapy with bowel rest and octreotide afforded no improvement in the pleural effusion(s). The patient was not considered a candidate for surgical therapy. Therefore, management with endoscopic retrograde cholangio-pancreatography (ERCP) and EUS was performed. ERCP confirmed the MRCP findings of ductal disruption with a disconnected pancreatic tail; the sub-diaphragmatic pancreatic fluid collection did not opacify with retrograde injection of contrast (Fig. 3). A transpapillary 7-French, single-pigtail

stent (Hobbs Medical Farnesyltransferase Co., Stafford Springs, CT, USA) was placed to facilitate drainage of the body and head of pancreas. EUS was performed using a linear-array echoendoscope (Olympus Corporation, Tokyo, Japan). The sub-diaphragmatic pancreatic fluid collection, attributable to the disconnected pancreatic tail, was targeted for EUS-guided therapy. Utilizing conventional techniques of EUS-guided pseudocyst drainage,6 the collection was accessed via transgastric needle puncture (Echo-tip 19-gauge needle, Cook Medical, Bloomington, IN, USA) in the gastric fundus. Cyst access was confirmed by fluid aspiration followed by contrast injection under fluoroscopy (Fig. 4). A 0.035 guide-wire was passed through the needle and coiled in the cavity of the collection (Fig. 5). The transgastric tract was dilated to 8 mm using a balloon catheter. Two 5-cm double-pigtail Solus stents (Cook Medical) were placed, each with one pigtail within the collection and the other within the gastric lumen (Figs. 6).