SESSION TITLE: Surgery Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Learning Objectives: When to suspect a urinothorax
CASE PRESENTATION: A 69 year old gentleman with a history of bladder CA s/p cystoproctectomy with urostomy and ileal conduit was admitted for weakness, dyspnea, and right sided pleuritic chest pain. In the previous month he had bilateral nephrostomy tubes placed for bilateral hydronephrosis. CXR revealed a right sided pleural effusion and CT scan demonstrated the right nephrostomy tube traversing the pleural space. Thoracentesis was performed revealing an exudate by LDH criteria (pleural LDH 338, serum 290). In addition creatinine was 1.79 and urea 44 in the pleural fluid, creatinine 1.87 and urea 42 in the serum. The ratio of pleural to serum creatinine was .95. He underwent an IR guided repositioning of the right nephrostomy tube with simultaneous drainage of the effusion with resolution of the effusion.
DISCUSSION: Urinothorax is urine in pleural space. Usually classified as traumatic and non-traumatic. Etiology for latter would include urinary obstruction of any cause including nephrolithiasis and malignancy.Trauma can be from renal biopsies, abdominal surgeries and nephrostomy tube placement. It is thought that urine leaks into abdomen and forms an urinoma which then enters the pleural cavity. It can also enter the pleural space via diaphragmatic defects. Historically they were thought to be transudative but case reports of exudative urinothorax have been reported in literature usually by LDH criteria. The pleural fluid to serum ratio of creatinine is usually >1 although does not have to be present for the diagnosis. The role of BUN in pleural fluid is not well defined in medical literature and if it can be used for diagnosis as well.
CONCLUSIONS: Our case shows a clear temporal relation between the placement of right nephrostomy tube which was found to traverse the pleural cavity with development of an effusion which resolved after the nephrostomy tube was repositioned. Fluid was negative for infection and malignancy and didn't recur during the last 1 year of follow up. This suggests that a urinothorax need not be a transudate and may not have a PF/serum creatinine ratio >1. His PF/Sr BUN ratio was >1 and the significance of this is not known. Urinothorax should be suspected in the appropriate clinical settings.
Reference #1: Bramley, Kyle, Puchalski, Jonathan. Defying Gravity Subdiaphragmatic Causes of Pleural Effusions. Clin Chest Med 34 (2013) 39-46.
Reference #2: Leonidas Laskaridis, Spyridon Kampantais, Chrysovalantis Toutziaris, Basileios Chachopoulos, Ioannis Perdikis, Anastasios Tahmatzopoulos, and Georgios Dimitriadis. Urinothorax—An Underdiagnosed Cause of Acute Dyspnea: Report of a Bilateral and of an Ipsilateral Urinothorax Case. Urologic Department, Aristotle University of Thessaloniki, 54635 Thessaloniki, Greece. Case Reports in Emergency Medicine, 2012
Reference #3: Stark, David, Shanes, Jeffrey, Baron, Richard, Koch, David. Biochemical Features of Urinothorax. Arch Intern Med-Vol 142, August 1982.
DISCLOSURE: The following authors have nothing to disclose: Kelly Walsma, Dennis Chairman, Dennis Suich
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