Hydronephrosis as a cause of pleural effusion.

Abstract

Certain abdominal and retroperitoneal diseases have been associated with pleural effusion without direct extension of the disease into the chest. Among these are ovarian and pelvic tumors (12), pancreatitis and carcinoma of the pancreas (6, 9, 13), cirrhosis of the liver (8, 9), subphrenic abscess (2), and retroperitoneal lymphoma (15). Overburdening of the lymphatic drainage from these organs or interruption of pleural drainage is the usual explanation for this relationship and is probably the main pathologic process. Pleural effusion has also been noted with chronic hereditary lymphedema (7), again implicating the lymphatic system. Experimental work has shown that the pleural cavity receives lymph from below the diaphragm in both health and disease (3, 12, 13). Recently, we have encountered two patients who presented with right-sided pleural effusion and were subsequently found to have hydronephrosis. When the lesions obstructing the outflow of urine were relieved, the pleural effusion abated. This led us to believe that there is a direct relationship between hydronephrosis and pleural effusion. The two clinical cases prompted us to investigate the lymphatic flow of an obstructed kidney and to attempt to produce pleural effusion in mongrel dogs by creating a hydronephrosis and altering the lymphatic flow of the pleural cavity in some of them. Case I: A 57-year-old white male was admitted to the Hospital of the University of Pennsylvania with a three-week history of right flank pain. This was occasionally felt in the left flank, and the week before admission a sharp shooting pain in the right shoulder began to develop. For three days prior to admission, he noted the onset of frequency, urgency, and a decrease in the caliber of his urinary stream. Four years before admission, a renal cyst had been excised, followed by a postoperative bout of urinary retention ascribed to a urethral stricture. Aside from bilateral inguinal herniorrhaphies more than twenty years prior to the present illness, there were no other significant features in the patient's history. The patient was in no acute distress on admission, and his vital signs were within normal limits. There was dullness at the base of the right lung, generalized tenderness in the abdomen, and moderate bilateral tenderness in the costovertebral angles. Small bilateral hydroceles and an enlarged benign prostate were found on rectal palpation. There was no peripheral edema. The hemogram was normal save for a white blood count of 10,800 with a differential shift to the left. Urinalysis was normal, and the urine was sterile. Blood urea nitrogen on admission was 51 mg per 100 cc, and serum creatinine was 3.6 mg per 100 cc. The fasting blood sugar was 135 mg per 100 cc, and an acid phosphatase was 0.4 unit. An electrocardiogram was normal.