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Retroperitoneal Fibrosis: Now Urine for a Pleural Predicament FREE TO VIEW

Chris Mosher, MD; Houssam Oueini, MD; Karina Serban, MD
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Indiana University School of Medicine, Indianapolis, IN

Chest. 2015;148(4_MeetingAbstracts):870A. doi:10.1378/chest.2279184
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SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Chronic transudative pleural effusions are often due to commonly encountered diseases such as heart failure or advanced liver disease. Here we report a case of complicated chronic transudative pleural effusion secondary to fibrosing mediastinitis and retroperitoneal fibrosis (RPF).

CASE PRESENTATION: A 51 year-old female presented with increased urinary frequency, right sided flank pain, and worsening dyspnea. Past medical history was significant for DVT, recurrent pulmonary embolism, and fibrosing mediastinitis from histoplasmosis complicated with SVC and right pulmonary artery occlusion leading to chronic right pleural effusion. Initial work up for nephrolithiasis was negative. Her symptoms worsened prompting a visit to the emergency department where an abdominal CT with contrast (Figure 1) demonstrated right side hydroureteronephrosis and a large right side pleural effusion. In pulmonary clinic, she complained of severe right flank pain and worsening shortness of breath. Chest CT was negative for PE but showed an increase in size of the right pleural effusion. Physical exam showed stable vital signs, normal pulse oximetry on ambient air, absent breath sounds in the right base, and right flank tenderness. Diagnostic thoracentesis revealed the following pleural fluid analysis: pH of 7.57, LDH 58, protein 2.0, glucose 105, cholesterol 25, triglycerides <10, bilirubin 0.3, creatinine1.2. Serum LDH was 302, protein 8.9, creatinine 1.14. Cytology, fungal, and AFB studies were negative. Results demonstrated a transudative effusion with an elevated fluid to serum creatinine ratio suggestive of urinothorax. Urology consultants recommended a repeat contrast abdominal CT (Figure 2), which demonstrated RPF leading to right ureter obstruction, hydronephrosis, and subsequently, urinothorax . Standard surgical (ureteral stent) and medical (high dose steroids, followed by mycophenolate mofetil) treatment for RPF was initiated. Significant clinical and radiologic improvement was seen at three months follow-up.

DISCUSSION: Urinothorax arises in two clinical scenarios: 1) trauma and 2) obstructive uropathy resulting in backpressure gradients favoring retroperitoneal lymphatic drainage into the negative pressure pleural space. Our case details a rare case of urinothorax presenting as the first manifestation of RPF. Obstructive uropathy from RPF is a rare cause of urinothorax in adulthood. Awareness of this entity in the right clinical setting is imperative in making the diagnosis as the pleural fluid creatinine level is typically not a part of the standard workup. Without appropriate diagnosis and intervention the risk of reaccumulation and secondary infection remains high.

CONCLUSIONS: This is the first documented case of a urinothorax prompting the diagnosis of histoplasmosis-related to RPF.

Reference #1: Dimitriadis, Georgios, et al. "Unilateral Urinothorax Can Occur Contralateral to the Affected Kidney." Scandinavian Journal of Urology 47.3 (2013): 242-43.

DISCLOSURE: The following authors have nothing to disclose: Chris Mosher, Houssam Oueini, Karina Serban

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