BREATHING IN URINE: IS THAT EVEN POSSIBLE?

Abstract

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Case report to evaluate a patient with a urinothorax. METHODS: Review of patient's hospital course via electronic medical record. RESULTS: Urinothorax, also known as urothorax, is a rare condition in which a pleural effusion forms as a result of accumulation of urine within the pleural space. Common causes include obstructive pathologies such as nephrolithiasis, ureteral stricture, or tumors. Less commonly, a urinothorax may be the result of genitourinary trauma or manipulation of the genitourinary tract during urologic or surgical intervention. A 43 year old male with past medical history significant for chronic nephrolithiasis was admitted for a right percutaneous nephrolithotripsy in the setting of multiple renal calculi with hydronephrosis. Stone removal and nephrostomy tube placement was conducted. Several hours post-procedure, he developed severe right shoulder and pleuritic chest pain refractory to intravenous pain medications. The patient developed dyspnea and worsening hypoxia. A chest x-ray done at this time showed a large right pleural effusion with compressive atelectasis of the right lower lung lobe. The pulmonology service was then consulted for further management. The patient subsequently underwent a thoracentesis with 1.3 liters of serosanguinous fluid removed. Diagnostic analysis of the fluid revealed a pH of 7.25, protein 1.1, lactate dehydrogenase 155, and creatinine of 6.03 resulting in a pleural fluid to serum creatinine ratio of 4.75. These findings were indicative of a urinothorax. The patient then developed reaccumulation of the pleural effusion and a chest tube was placed with an additional 1 liter of fluid removed. He was started on empiric antibiotic therapy which was discontinued once cultures resulted as negative. With continued drainage of urine through the nephrostomy tube that was in place, the amount of pleural fluid drainage improved significantly. The patient’s symptoms and radiographic findings also resolved. Ultimately, the chest tube was removed once the pleural creatinine was measured to be less than one. CONCLUSIONS: Less than seventy cases of urinothorax have been reported since 1968 (Lee et al, 2018) making this a rare pathophysiologic phenomenon. This case highlights the importance of understanding rare causes of pleural effusions including urinothorax. A thorough history and physical exam is vital to help establish diagnosis in a timely fashion for early therapeutic intervention. Once urinothorax is suspected, thoracentesis should be performed for pleural fluid analysis to allow for accurate diagnosis. Patients often need pleural fluid drainage while concurrent treatment of the underlying urologic problem is pursued. Once discharged from the hospital, patients should be followed closely in the outpatient setting. CLINICAL IMPLICATIONS: As above. DISCLOSURES: No relevant relationships by Christopher Chew, source=Web Response No relevant relationships by Sameena Salcin, source=Web Response No relevant relationships by Molla Teshome, source=Web Response