A Unique Case of Chest and Abdominal Pain

Abstract

SESSION TITLE: Plueral CasesSESSION TYPE: Affiliate Case Report SlidePRESENTED ON: Monday, October 26, 2015 at 11:00 AM - 12:00 PMINTRODUCTION: Urinothorax is a rare cause of pleural effusion and can result from injury to the urinary tract or obstructive uropathy. We report a unique case of urinothorax.CASE PRESENTATION: A 35 year-old man presented to the emergency room with chest and abdominal pain over the past 5 weeks. He has a history of Von Hippel-Lindau syndrome for which he required laparoscopic radiofrequency ablations in 2006 and 2008. In the interim he has received percutaneous microwave ablations in 2011- 2013 and most recently in November 2014. After the percutaneous microwave ablation he experienced right sided abdominal tenderness and swelling as well as right sided chest pain. Chest radiography and thoracic Computer Tomography showed a new right pleural effusion. There was also a significant rise in patient's serum creatinine from baseline. Initial thoracentesis revealed an exudate. The fluid quickly re-accumulated and subsequent thoracentesis revealed a transudate. Pleural fluid creatinine was 7.7mg/dl and a nephro-pleural fistula with urinothorax was diagnosed. A nuclear medicine renal scan - 99mTc-Mercaptoacetyltriglycine (MAG-3) was obtained and showed tracer migration from the renal collecting system into the right pleural space. The effusion required placement of a pig tail catheter. The fluid continued to recur following attempted percutaneous catheter drainage and the patient subsequently underwent a nephrectomy in March 2015.DISCUSSION: Urinothorax due to obstructive uropathy usually presents as bilateral pleural effusions, while traumatic urinothorax results in unilateral urinothorax. Plural fluid analysis can help confirm the diagnosis. A pleural fluid-to-serum creatinine ratio >1 suggests possible urinothorax. Urinothorax is also typically associated with low protein levels, high LDH levels and low pH. Imaging with contrast-enhanced CT or renal nuclear studies, such as 99mTc-MAG-3, can be helpful by demonstrating migration of contrast from the renal collecting system into the pleural space. Treatment involves relieving urinary obstruction, if present, and draining the effusion if the patient is symptomatic. If urinothorax fails to improve with conservative approaches surgical intervention may be required.CONCLUSIONS: We present an exceedingly rare case of urinothorax resulting from percutaneous microwave ablation in a patient with Von Hippel-Lindau syndrome, with persistent post-procedural pleural effusion requiring a nephrectomy.Reference #1: A. Handa, R. Agarwal, A.N. Aggarwal Urinothorax: an unusual cause of pleural effusionDISCLOSURE: The following authors have nothing to disclose: Kashif Yaqub, Kenneth Sakata, Robert ViggianoNo Product/Research Disclosure Information SESSION TITLE: Plueral Cases SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 26, 2015 at 11:00 AM - 12:00 PM INTRODUCTION: Urinothorax is a rare cause of pleural effusion and can result from injury to the urinary tract or obstructive uropathy. We report a unique case of urinothorax. CASE PRESENTATION: A 35 year-old man presented to the emergency room with chest and abdominal pain over the past 5 weeks. He has a history of Von Hippel-Lindau syndrome for which he required laparoscopic radiofrequency ablations in 2006 and 2008. In the interim he has received percutaneous microwave ablations in 2011- 2013 and most recently in November 2014. After the percutaneous microwave ablation he experienced right sided abdominal tenderness and swelling as well as right sided chest pain. Chest radiography and thoracic Computer Tomography showed a new right pleural effusion. There was also a significant rise in patient's serum creatinine from baseline. Initial thoracentesis revealed an exudate. The fluid quickly re-accumulated and subsequent thoracentesis revealed a transudate. Pleural fluid creatinine was 7.7mg/dl and a nephro-pleural fistula with urinothorax was diagnosed. A nuclear medicine renal scan - 99mTc-Mercaptoacetyltriglycine (MAG-3) was obtained and showed tracer migration from the renal collecting system into the right pleural space. The effusion required placement of a pig tail catheter. The fluid continued to recur following attempted percutaneous catheter drainage and the patient subsequently underwent a nephrectomy in March 2015. DISCUSSION: Urinothorax due to obstructive uropathy usually presents as bilateral pleural effusions, while traumatic urinothorax results in unilateral urinothorax. Plural fluid analysis can help confirm the diagnosis. A pleural fluid-to-serum creatinine ratio >1 suggests possible urinothorax. Urinothorax is also typically associated with low protein levels, high LDH levels and low pH. Imaging with contrast-enhanced CT or renal nuclear studies, such as 99mTc-MAG-3, can be helpful by demonstrating migration of contrast from the renal collecting system into the pleural space. Treatment involves relieving urinary obstruction, if present, and draining the effusion if the patient is symptomatic. If urinothorax fails to improve with conservative approaches surgical intervention may be required. CONCLUSIONS: We present an exceedingly rare case of urinothorax resulting from percutaneous microwave ablation in a patient with Von Hippel-Lindau syndrome, with persistent post-procedural pleural effusion requiring a nephrectomy. Reference #1: A. Handa, R. Agarwal, A.N. Aggarwal Urinothorax: an unusual cause of pleural effusion DISCLOSURE: The following authors have nothing to disclose: Kashif Yaqub, Kenneth Sakata, Robert Viggiano No Product/Research Disclosure Information