Disorders of the Pleura: Student/Resident Case Report Poster - Disorders of the Pleura |

Urinothorax With a Dual Diagnosis FREE TO VIEW

Amit Chopra, MD; Christopher Schaefer, MD; Rahul Argula, MD; John Huggins, MD
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Albany Medical Center, Albany, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):584A. doi:10.1016/j.chest.2016.08.673
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: The diagnosis of recurrent transudative pleural effusions can be challenging, especially when competing mechanisms could be contributing to the collection and persistence of fluid in the pleural space. Here we present a case of recurrent pleural effusion with dual diagnosis.

CASE PRESENTATION: 83 year old female presents with recurrent right sided pleural effusion. In the past two years the patient had undergone three thoracentesis which had revealed clear transudative effusions. Her history was notable for a pacemaker placement complicated with hemothorax ten years earlier and multiple uncomplicated cystoscopic surgeries and urinary tract instrumentation for urinary incontinence. After chest radiograph revealed moderate right size pleural effusion thoracentesis was performed revealing 1220 mL yellow clear fluid with pH of 7.47, pleural to serum protein ratio of 0.32, pleural to serum LDH of 0.28 consistent with transudate. Pressure volume curve during the thoracentesis revealed biphasic curve (Img 2), suspicious for dual process of trapped lung and additional cause of transudative effusion. Pleural fluid creatinine was 1.2 and the pleural to serum Cr ratio was 1.1, raising suspicion of urinothorax. This suspicion was further investigated with a 99Tm radionuclide renal scintigraphy scan which suggested communication between the right kidney and right pleural space.(Img 1) A CT was performed, showing visceral pleural lung thickening, consistent with trapped lung.

DISCUSSION: Urinothorax is diagnosed when there is urine present in the pleural space. The most common cause of this is injury, obstructive uropathy or instrumentation of the urinary tract. The urine extravasates into the pleural space either directly or through retroperitoneal lymphatics. A pleural to serum creatinine >1 can suggest and nuclear imaging showing 99Tc labeled albumin extravasating from the urinary tract to pleural space can confirm the diagnosis. Trapped lung is diagnosed when the lung fails to expand resulting in space between the visceral and parietal pleura. The diagnosis can be suggested by history, imaging, and manometry. The biphasic elastance curve in combination with radiographic evidence and history of lung trauma suggested the dual diagnosis of both trapped lung and urinothorax.

CONCLUSIONS: The presence of a biphasic P-V curve in a patient with a transudative PFA can only occur as a result of dual mechanisms, with one cause being the trapped lung and the other process resulting in the collection of more transudative fluid in the pleural space (urinothorax in this case)

Reference #1: Stark DD,Shanes JG,Baron RL,Koch DD. Biochemical features of urinothorax. Archives of internal medicine1982;142:1509-11

Reference #2: Garcia-Pachon E,Romero S. Urinothorax:a new approach. Current opinion in pulmonary medicine2006;12:259-63

Reference #3: Ranjan V,Agrawal S,Chipde SS,Dosi R. Urinothorax:A path, less travelled:Case report and review of literature. Journal of natural science, biology,and medicine2015;6:213-6

DISCLOSURE: The following authors have nothing to disclose: Amit Chopra, Christopher Schaefer, Rahul Argula, John Huggins

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