Urinothorax: a rapidly accumulating transudative pleural effusion in a 64-year-old man.
Abstract: We report the case of a 64-year-old man who developed a rapid, right-sided pleural effusion. On initial presentation to the emergency room, the patient had fever and flank pain consistent with a ureteral obstruction (due to a bladder tumor) and associated hydronephrosis that had required previous placement of a pericuta-neous nephrostomy tube. After a 10-day stay in the hospital, the patient's urine output ceased. Symptomatic dyspnea with radiographic radiographic (rā´dēōgraf´ik),
adj relating to the process of radiography, the finished product, or its use. evidence of a new pleural effusion soon followed. Urinothorax was the etiology of the effusion effusion /ef·fu·sion/ (e-fu´zhun)
1. escape of a fluid into a part; exudation or transudation.
2. effused material; an exudate or transudate. .
Key Words: urinothorax, nephropleural fistula fistula (fĭs`chlə), abnormal, usually ulcerous channellike formation between two internal organs or between an internal organ and the skin. , pleural effusions, percutaneous nephrostomy
Urinothorax, the presence of urine within the pleural cavity, is a very rare cause of transudative pleural effusions. The most obvious and frequently reported causes involve urinary tract obstruction/trauma leading to hydronephrosis and urioma formation within the retroperitoneum. This, we feel, is the most likely explanation for the accumulation of urine within our patient's lung.
Our patient, a 64-year-old man, presented to the emergency room with complaints of nausea and vomiting Nausea and Vomiting Definition
Nausea is the sensation of being about to vomit. Vomiting, or emesis, is the expelling of undigested food through the mouth. , flank pain, and a fever of 102[degrees]. He had a prior diagnosis of bladder cancer, small cell variant, and no surgical treatment was initiated. Records noted that 2 weeks prior, a right nephrostomy tube was placed due to ureter ureter (yrē`tər), thick-walled tube that conveys urine from the kidney to the urinary bladder. It is approximately 10 in. (25. obstruction and associated hydronephrosis.
Upon physical examination, the patient appeared to be in no acute distress. The right lower lung was noted to have decreased breath sounds, and crackles were noted in the right middle lobe. The abdomen was mildly distended distended Medtalk Enlarged, bloated. Cf Nondistended. , and there was bilateral flank tenderness on palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. . A nephrostomy tube was noted to be emerging from the posterior right thoracic cage at the level of T10.
Laboratory results yielded a normal, complete blood count. Basic metabolic panel A basic metabolic panel (BMP) is a set of seven or eight blood chemical tests. Components
The version with seven tests is also known as "CHEM-7". The seven parts of a CHEM-7 include tests for:
A group of several cell types that occur in the bloodstream and are essential for a properly functioning immune system.
Mentioned in: Abscess Incision & Drainage, Bone Marrow Transplantation, Complement Deficiencies (WBC WBC white blood cell; see leukocyte.
white blood cell
n stands for white
cell. ), 40 to 50 red blood cells Red blood cells
Cells that carry hemoglobin (the molecule that transports oxygen) and help remove wastes from tissues throughout the body.
Mentioned in: Bone Marrow Transplantation
red blood cells (RBC RBC red blood cell.
RBC or rbc
red blood cell
n See red blood cell count.
red blood cells; red blood (cell) count (see blood count). ), and 100 + protein. In addition, a 24-hour urine total protein was 1092 mg (<150). Urine culture revealed no growth at 48 hours. Sputum culture grew P aeruginosa. Admission chest x-ray showed right basilar basilar /bas·i·lar/ (bas´i-lar) pertaining to a base or basal part.
Of, relating to, or located at or near the base, especially the base of the skull. atelectasis atelectasis
or lung collapse
Lack of expansion of pulmonary alveoli (see pulmonary alveolus). With a large-enough collapsed area, the victim stops breathing. with possible pneumonia (Fig. 1).
The patient was administered antibiotics and remained stable over the next 10 days. On day 11, his serum creatinine increased to 5.3 mg/dL and urinary output ceased. This trend continued into day 12 when a pulmonary consult was requested due to severe dyspnea. Repeat LDH LDH -lactate dehydrogenase.
lactic acid dehydrogenase; see lactate dehydrogenase. was 149 mg/dL and creatinine was 6.6 mg/dL. The chest x-ray (Fig. 2) and computed tomography (Fig. 3) scan revealed a large fluid collection in the right lower lobe with compression of the right lung.
Our patient's differential was somewhat challenging. The pleural fluid was a transudate transudate /tran·su·date/ (tran´su-dat) a fluid substance that has passed through a membrane or has been extruded from a tissue; in contrast to an exudate, it is of high fluidity and has a low content of protein, cells, or solid , with a normal pH, and a pleural Pleural
Pleural refers to the pleura or membrane that enfolds the lungs.
Mentioned in: Pneumothorax
emanating from or pertaining to the pleura. to serum ratio of LDH (0.168). The key criteria for the diagnosis of urinothorax, a pleural to serum creatinine ratio of >0.6, was present however, with a documented level at 1.96. (1,2)
Thoracentesis was performed and yielded 1.5 L of straw-colored fluid. Fluid analysis revealed a total protein of less than 1.0, pH of 7.5, LDH 25 mg/dL, glucose 115 mg/dL, creatinine 13 mg/dL, WBCs of 164, and RBCs of 208. Significant effusion persisted and a chest tube was inserted with 3.0 L of residual fluid removed. The patient died one week later due to his declining renal function and other causes.
Few cases of urinothorax have been reported. In 2004, Garcia-Pachon and Navas (3) found only 53 cases documented in the literature. However, lack of reported cases may in large part be due to lack of suspicion. Few pulmonologists list urine accumulation in their differentials when encountering a rapidly accumulating pleural effusion.
While most cases of urinothorax are due to obstruction, secondary to tumor/metastasis, or trauma of the ureter, there have been other reported causes. Retroperitoneal fibrosis, shock wave lithotripsy, and removal/blockage of nephrostomy tubes may result in the formation of an urioma. (3-5) A nephropleural fistula may form, allowing urine to enter the pleural cavity. (6) Another reported cause, and the likely origin of our case, is the placement of nephrostomy tubes too cephalically in the thorax. It is estimated that 0.5 to 1% of patients requiring pericutaneous nephrostomy placement may develop nephropleural fistulas. (7,8)
Diagnosis of urinothorax is similar to any pleural effusion. A chest x-ray and ultrasound are often obtained first, but in many cases a CT scan is required. If there is radiographic evidence of fluid, a diagnostic and therapeutic thorocentesis is indicated. (4-11) The evaluation to differentiate between transudates and exudates usually follows Light criteria (12) (Fig. 4) and include the following laboratory modalities: cytology, protein, LDH, pH, Gram stain, and culture and sensitivity. (3,13)
[FIGURE 1 OMITTED]
[FIGURES 2 & 3 OMITTED]
Urinothorax should be suspected if the sample is straw colored or has a urine-like odor. (4,6) Measurement of pleural creatinine to serum creatinine has been found to be the most reliable laboratory value and should be the definitive evaluation of urinothorax. (9,13) The average pleural fluid to serum creatinine ratio reported in 12 cases by Garcia-Parcho was 9.15 (range 1.09-19.8). (1-3) Secondly, due to the pH of urine pH of urine Lab medicine Urine pH-UP has a wider range than does blood; the kidneys and lungs maintain the pH of the circulation near neutral; UP is ↑ by alkaline excess, diet–↑ fruits & vegetables, drugs–acetazolamide, aldosterone, , fluid in a urinothorax may be both transudative and acidic (<7.30). (3,9-11) Finally, a subtle deviation from Light criteria (12) may be found when pleural fluid contains urine; LDH levels may be high in comparison to serum levels. (3,13)
This case suggests that Light criteria (12) for the diagnosis of exudative exudative
of or pertaining to a process of exudation.
a disease of young pigs and chickens caused by a nutritional deficiency of vitamin E. Characterized by severe edema of the subcutaneous tissues. pleural fluid will correctly differentiate between exudates and transudates, thus aiding the physician in the diagnosis. In addition, in the presence of urine, the pleural fluid will contain a higher creatinine level than in the serum. Urinothorax should be included in the differential in patients with hydronephrosis, (14) renal pathology or recent placement of a percutaneous nephrostomy tube.
Our sincerest gratitude is extended to Abingdon Internal Medicine and Associates, Johnston Memorial Hospital, and Edward Via Virginia College of Osteopathic Medicine The Edward Via Virginia College of Osteopathic Medicine, often referred to as simply VCOM, is a private, non-profit osteopathic medical school located in Blacksburg, Virginia. .
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RJA Red Jumpsuit Apparatus (band)
RJA Rolf Jensen & Associates
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Do just once what others say you can't do, and you will never pay attention to their limitations again. --Captain James Cook
Samuel Deel, MS-4, BS, and Emory Robinette Jr, MD, FCCP FCCP Fellow of the American College of Chest Physicians
FCCP Fellow of the American College of Clinical Pharmacy
FCCP Feeder Calf Certification Program
FCCP Family-Controlled Corporation Program (The Wharton School)
From Edward Via Virginia College of Osteopathic Medicine, Abingdon Internal Medicine Associates, and Johnston Memorial Hospital, Blacksburg, VA.
Reprint requests to Edward Via Virginia College of Osteopathic Medicine, c/o Sam Deel, 2265 Kraft Drive, Blacksburg, VA 24060. Email: firstname.lastname@example.org
Accepted July 12, 2006.
RELATED ARTICLE: Key Points
* Urinothorax should be considered in patients with described renal pathology.
* Light criteria for pleural fluid diagnosis should be followed.
* It is important to evaluate both the pleural and serum creatinine levels in patients with rapidly accumulating effusions.
Light Criteria (5) 1) Pleural fluid protein/serum protein ratio greater than 0.5. 2) Pleural fluid LDH/serum LDH ratio greater than 0.6. 3) Pleural fluid LDH greater than two thirds the upper limits of normal of the serum LDH. Fig. 4 Light criteria for pleural fluid diagnosis.