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

Urinoma With Unilateral Urinothorax FREE TO VIEW

Adam Austin, MD; Amit Chopra, MD
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Albany Medical College, Albany, NY

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

Chest. 2016;150(4_S):586A. doi:10.1016/j.chest.2016.08.675
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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: Urinothorax is an uncommon, but under-recognized complication of obstructive uropathy and upper genitourinary tract injury with approximately eighty cases described in the literature. In this report, we describe an unusual case of urinothorax in the setting of an ipsilateral urinoma.

CASE PRESENTATION: A 53 year-old woman with history of multiple sclerosis and neurogenic bladder presented to our medical center with dyspnea, fever and decreased urine output. A chest radiograph demonstrated a large left pleural effusion (Figure 1). A large volume thoracentesis was performed and more than one liter of serous yellow pleural fluid was removed. Pleural fluid analysis showed a transudative effusion with pH 7.45 and a creatinine/serum ratio of 1.10. Computed tomography (Figure 2) revealed bilateral hydronephrosis with staghorn calculi and a left-sided urinoma. Aspiration of urinoma exhibited a creatinine level of 9.4 mg/dL. After bilateral percutaneous nephrolithotomies and drainage of the urinoma, the left urinothorax resolved completely.

DISCUSSION: The diagnosis of urinothorax requires a high degree of clinical suspicion. Pleural fluid analysis is commonly consistent with a transudate with pH less than 7.40 (1). However, when the pH is higher than 7.40, it tends to be in cases of urinary tract infection with ammonia producing and urease-splitting bacteria, such as proteus or klebsiella (2), or in this case, staphylococcus aureus. The most specific and definitive biochemical feature of an urinothorax is the presence of high pleural fluid creatinine levels and a pleural fluid/serum creatinine ratio greater than 1. Concurrent CT abdomen may reveal an ipsilateral upper genitourinary (GU) lesion with a retroperitoneal fluid collection (urinoma) communicating with the pleural space. Nuclear imaging using radionuclide technetium-99m-mercaptoacetyltriglycine-3 or technetium-99m DTPA (diethylenetriaminepentaacetic acid) scintigraphy confirms the diagnosis of urinothorax by demonstrating a leakage of the dye from the GU tract into the pleural space (3). Urinothorax resolves immediately upon relief of the obstructive uropathy.

CONCLUSIONS: A Urinothorax should be suspected in cases of unilateral pleural effusions associated with urinary obstruction, genitourinary manipulation or renal trauma. Attention to the sub-diaphragmatic structures, such as the kidney, may reveal the presence of hydronephrosis, and quickly render a diagnosis of urinothorax.

Reference #1: Garcia-Pachon E, Romero S. Urinothorax: a new approach. Curr Opin Pulm Med. 2006; 12: 259-263.

Reference #2: Broomfield RJ, Morgan SD, Khan A, Stickler DJ. Crystalline bacterial biofilm formation on urinary catheters by urease-producing urinary tract pathogens: a simple method of control. J Med Microbiol. 2009; 58:1367-75.

Reference #3: Bhattacharya A, Venkataramarao SH, Kumar S, Mittal BR. Urinothorax demonstrated on 99mTc Ethylene dicysteine renal scintigraphy. Nephrol Dial Transplant. 2007; 22:1782-3.

DISCLOSURE: The following authors have nothing to disclose: Adam Austin, Amit Chopra

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