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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 6  |  Page : 2155-2157  

An unusual case of urinothorax after percutaneous nephrostolithotomy


1 William Beaumont Hospital, Family Medicine Residency, Troy, Michigan, USA
2 William Beaumont Hospital, Family Medicine Residency; Department of Family Medicine, Oakland University William Beaumont School of Medicine, Troy, Michigan, USA

Date of Submission23-Jan-2017
Date of Decision08-Feb-2017
Date of Acceptance14-Nov-2017
Date of Web Publication26-Jun-2019

Correspondence Address:
David Lick
44250 Dequindre Rd., Sterling Heights, MI 48314
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_28_17

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  Abstract 


We present here a case of severe dyspnea after a percutaneous nephrostolithotomy, which resulted from an urinothorax, an uncommon complication of posturological procedures. Chest X-ray indicated a significant left pleural effusion, and a diagnosis was confirmed by the pleural fluid analysis. Chest tube placement did not improve the patient's clinical status; retrograde pyelogram was performed, and a stent was placed in the left ureter orifice where a narrowing was discovered. Correcting the cause of the urinothorax is the key in such cases of severe pleural effusions as seen in our case.

Keywords: Percutaneous nephrostolithotomy, phenazopyridine, pleural effusion, urinothorax


How to cite this article:
Dregoesc D, Kelley R, Lick D. An unusual case of urinothorax after percutaneous nephrostolithotomy. J Family Med Prim Care 2019;8:2155-7

How to cite this URL:
Dregoesc D, Kelley R, Lick D. An unusual case of urinothorax after percutaneous nephrostolithotomy. J Family Med Prim Care [serial online] 2019 [cited 2019 Jul 23];8:2155-7. Available from: http://www.jfmpc.com/text.asp?2019/8/6/2155/261407




  Introduction Top


Urinothorax, an accumulation of urine in the pleural space, is a rare and unusual cause of a pleural effusion with <100 reported cases in the literature.[1] This is seen in patients with obstructive uropathy,[2],[3],[4] blunt abdominal trauma,[5],[6],[7] and percutaneous renal and ureteral procedures.[8] Pleural fluid analysis obtained through thoracentesis offers the diagnosis for urinothorax by measurement of creatinine and calculating the ratio of pleural fluid creatinine relative to serum creatinine, with a value >1 indicative for urinothorax.[9] Understanding diagnostic features, different treatment options, and outcomes will help in early diagnosis and therapeutic intervention for urinothorax. We present here a case of urinothorax after percutaneous nephrostolithotomy, which did not resolve with thoracostomy and chest tube placement until the underlying urological etiology was discovered and addressed. This case underlines the importance of utilizing imaging and interventional procedures to correct the underlying problem.


  Case Report Top


A 57-year-old female with past medical history of thyroid cancer status postthyroidectomy, kidney stones, and chronic kidney disease presented to the emergency department with acute onset of shortness of breath, fever, and left-sided chest pain. The chest pain had progressively worsened over the past 3 days.

The patient underwent left nephrolithotomy 7 days prior for symptomatic renal calculi with insertion of a left nephrostomy tube and its removal 5 days later. The patient was taking sulfamethoxazole–trimethoprim (double strength) and phenazopyridine at presentation.

The patient was visibly in pain breathing 18 breaths/min with an oxygen saturation of 92% on room air and normal remaining vital signs. Examination demonstrated decreased breath sounds and dullness to percussion over the lower two-thirds of the left chest.

Laboratory work showed an unremarkable CBC. Blood urea nitrogen was 24 mg/dL, serum creatinine was 1.19 mg/dL (patient's baseline was 0.65 mg/dL), and glomerular filtration rate was calculated to be 47 ml/min/1.73 m 2 (patient's baseline was 90 ml/min/1.73 m 2). Urinalysis showed positive nitrites, positive leukocyte esterase, 1 + bacteria, 28 leukocytes, and 37 epithelial squamous cells. The urine was orange in color consistent with phenazopyridine treatment. Chest radiograph revealed a significant left pleural effusion [Figure 1].
Figure 1: Large left pleural effusion

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A chest tube was placed through the left fourth intercostal space, and 2 L of fluid was removed. The fluid was yellow and blood tinged, with an odor and appearance resembling urine. The fluid analysis revealed a leukocyte count of 2060/μL, pH of 6.69, glucose of 104 mg/dL, protein of <2 g/dL, lactate dehydrogenase (LDH) of 342 U/L, and creatinine of 5.50 mg/dl. The pleural fluid creatinine to serum creatinine ratio was 4.6. Fluid cultures and cytology were negative. Based on the appearance of the pleural fluid and the elevated serum to fluid creatinine ratio, the patient was diagnosed with urinothorax.

The patient was initially managed conservatively with a chest tube and catheter placement; however, the chest tube fluid output persisted, so a cystoscopy with left retrograde pyelogram was performed that revealed a narrowing in the ureter orifice, and subsequently, a left ureteral stent was placed. After the procedure, the chest tube output decreased significantly, urine output improved, and the patient's symptoms resolved within few days.


  Discussion Top


A rare and unusual etiology of a pleural effusion is an urinothorax, which is urine accumulation in the pleural space. The development of urinothorax is hypothesized to occur as a result of one of two different mechanisms: direct passage of urine through an anatomical defect in the diaphragm or by diaphragmatic lymphatics through the retroperitoneal space.[10]

Interestingly, our patient was taking phenazopyridine, which was evident by the typical orange discoloration of the urine but not the pleural fluid. This favors an indirect passage of urine into the pleural cavity instead of through a direct defect in the diaphragm. The exact mechanism by which the orange discoloration did not follow the urine into the chest is unknown, and to the best of our knowledge, this is the first report of this kind.

Pleural fluid analysis confirms the diagnosis of urinothorax in most cases. Previously reported diagnostic criteria were used in this case including a pleural fluid creatinine to serum creatinine ratio >1.0 and a low pleural fluid pH.[11] A typical urinothorax will have the characteristics of transudate per Light's criteria. However, an urinothorax may have an elevated LDH level, and therefore, the effusion may be interpreted as an exudate. This was seen in our patient, and to the best of our knowledge, only few other cases have reported an exudative pleural effusion.[9],[12],[13]

Imaging is often used to confirm the pleural effusion collection as well as the underlying process. X-rays, renal scans, contrast-enhanced computed tomography, and pyelograms may all be used to establish the location of the urine leakage.

Treatment of an urinothorax involves evacuation of the fluid from the pleural space and correction of the underlying deficit in the urinary tract. Thoracentesis or thoracostomy is typically used to evacuate the pleural fluid. Treatment of the underlying cause is based on the mechanism of injury and may involve ureteral stenting or surgery.[14],[15] Urinothorax, although rare, may be underdiagnosed, and therefore, it is important to have a high index of suspicion in patients with unknown cause of pleural effusion and recent history of urological pathology or procedure. These cases typically need a consult to urology, and awareness is important for an early diagnosis and treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Corriere JN Jr., Miller WT, Murphy JJ. Hydronephrosis as a cause of pleural effusion. Radiology 1968;90:79-84.  Back to cited text no. 1
    
2.
Belis JA, Milam DF. Pleural effusion secondary to ureteral obstruction. Urology 1979;14:27-9.  Back to cited text no. 2
    
3.
Leung FW, Williams AJ, Oill PA. Pleural effusion associated with urinary tract obstruction: Support for a hypothesis. Thorax 1981;36:632-3.  Back to cited text no. 3
    
4.
Perinetti EP. Urinous pleural effusion associated with obstructive nephropathy. Medicina (B Aires) 1978;38:691-4.  Back to cited text no. 4
    
5.
Capellier G, Gaussorgues P, Boyer F, Claud B, Robert D. Diagnosis of post-traumatic pleural effusion. Ann Fr Anesth Reanim 1989;8:131-2.  Back to cited text no. 5
    
6.
Hase T, Kodama M, Domasu S, Nakamura K, Morita K, Tarumi T, et al. A case of urothorax that manifested as posttraumatic pleural effusion after a motorcycle crash. J Trauma 1999;46:967-9.  Back to cited text no. 6
    
7.
Gandhi RK, Dhandapani BS, Barvadheesh RC. Combination injuries of diaphragm and urinary bladder resulting urinothorax. J Minim Access Surg 2015;11:149-50.  Back to cited text no. 7
    
8.
Abdel-Rahman AM. Urinothorax: A rare finding after urinary intervention. Clin Respir J 2017;11:529-31.  Back to cited text no. 8
    
9.
Garcia-Simon R, Hergueta Herrera J, Cañizares Oliver S, Roldan Rivas F, Fabre González E. Urinothorax: An unusual complication of an oncologic gynecological surgery. Taiwan J Obstet Gynecol 2015;54:336-8.  Back to cited text no. 9
    
10.
Bhattacharya A, Venkataramarao SH, Kumar S, Mittal BR. Urinothorax demonstrated on 99mTe ethylene dieysteine renal scintigraphy. Nephrol Dial Transplant. 2007;22;1782-3.  Back to cited text no. 10
    
11.
Gurtner B. Urine in the wrong place: Urothorax. Schweiz Rundsch Med Prax 1994;83:30-5.  Back to cited text no. 11
    
12.
Mora RB, Silvente CM, Nieto JM, Cuervo MA. Urinothorax: Presentation of a new case as pleural exudate. South Med J 2010;103:931-3.  Back to cited text no. 12
    
13.
Salvache MS, Amigo XP. Urinothorax: Always a transudative pleural effusion? Arch Broncho Neumol 2008;44:285-6.  Back to cited text no. 13
    
14.
Izzo L, Caputo M, De Toma G, Izzo P, Bolognese A, Basso L, et al. Urinoma and urinothorax: Report of a case. Am Surg 2008;74:62-3.  Back to cited text no. 14
    
15.
Ranjan V, Agrawal S, Chipde SS, Dosi R. Urinothorax: A path, less travelled: Case report and review of literature. J Nat Sci Biol Med 2015;6:213-6.  Back to cited text no. 15
    


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