Fortuitous bilothorax: a picture is worth a thousand words

We present a 91-year-old male was admitted in Clinical Hospital of Valladolid (Spain), due to respiratory infection and acute respiratory failure. Given his torpid evolution and increased oxygen requirements, the new X-ray showed submassive right pleural effusion. Thus, we carried out diagnostic thoracentesis and placed a endothoracic drainage. The greenish turbid pleural fluid (PF) was polymorphonuclear exudate, establishing the diagnosis of bilothorax by the presence of bilious pleural effusion (PF/Serum bilirubin > 1). The thoraco-abdominal CT scan showed a subphrenic abscess with an interruption in right diaphragmatic dome, accompanied by collections around the holed gallbladder. Subsequently, it was placed a biliary drainage and antibiotherapy was adjusted to the growth of C. albicans and E. faecalis in PF, with favorable recovery after surgery. It is essential to make a detailed review of patients’ complementary tests, owing to the X-ray was suspicious of subphrenic abscess with hydroaerial level, but it was erroneously classified as situs inversus with levocardia.