URINOTHORAX: A RARE CAUSE OF PLEURAL EFFUSION AFTER ELECTIVE NEPHROLITHOTOMY

Abstract

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Urinothorax is a rare condition that consists of the accumulation of urine in the pleural space usually due to trauma or obstruction of the genitourinary tract[1,2]. Its rarity makes diagnosis and treatment challenging. Below, we present a case of unilateral urinothorax after elective nephrolithotomy. CASE PRESENTATION: A 54-year-old female with recurrent urinary tract infections, nephrolithiasis, and chronic kidney disease presented to the hospital for elective nephroureteral catheter placement and nephrolithotomy for a 2cm right kidney stone. On admission, a 24fr catheter was placed into the right renal pelvis. Post-procedure, she appeared well and complained of mild pain around the catheter site. Imaging confirmed satisfactory position of the catheter. The next day, she underwent right percutaneous nephrolithotomy. During the procedure, the catheter was replaced with a dual-lumen access catheter using fluoroscopy. The surgeon noted that the tract was more medial than the usual tract. The stone was treated with lithotripsy and a sterile catheter was replaced into the renal pelvis. Post-operatively, she complained of dyspnea and pain at the catheter site. She rapidly developed respiratory distress and hypoxia, requiring supplemental oxygen via a non-rebreather. Examination and imaging were consistent with a right pleural effusion. The existing nephroureteral catheter was downsized and a chest tube was inserted with drainage of 2L of serosanguinous fluid from the pleural space. The patient improved and the effusion remained stable. Two days later, she developed acute respiratory distress due to re-accumulation of pleural fluid. A nephrostogram revealed no communication between the catheter and pleural space. Pleural fluid studies demonstrated a transudate with pH 7.4, LDH 177, creatinine 2.8 (serum creatinine 1.4). Her symptoms improved over the next three days. A repeat CT showed improvement in the effusion but loculations were noted. Surgical intervention was considered but deferred. The chest tube was removed and she was discharged. She did well with resolution of the loculations and did not require surgical decortication. DISCUSSION: Given the rare (likely underdiagnosed) nature of a urinothorax, knowledge surrounding its clinical course, pleural fluid characteristics, and best treatment is lacking. A recent review concluded that most cases of urinothorax are unilateral, of traumatic (commonly surgical) origin, have a high LDH, pleural fluid/serum creatinine ratio >1.0, and/or pH <7.3[2]. Dyspnea was the primary symptom[2]. Successful treatment focused on the underlying uropathy, with or without thoracentesis[2]. Decortication was performed in a small number of patients with a favorable outcome in all[2]. CONCLUSIONS: This case demonstrates a rare complication of urologic procedures for which increased awareness and clinical suspicion may aid in its timely diagnosis and management. Reference #1: Austin A, Johani SN, Brasher PB, Argula RG, Huggins JT, Chopra A. The urinothorax: a comprehensive review with case series. Am J Med Sci. 2017;354(1):44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systemic review. J Thorac Dis. 2017;9(5):1209-1218. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by George Lieb, source=Admin input