Case report ESIM 9

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Case reportESIM 9

• An unexpected cause
• Of pleural effusion

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Case report

• A 73-year-old man was admitted to the internal
  medicine ward because of dyspnea and a large left
  pleural effusion on chest x-ray .

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Case report

• He had history of
• Hypertension
• Coronary artery disease
• Benign hypertrophy of the prostate
• Chronic renal failure with a serum
  creatinine level of 3.0-3.2 mg/dl

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Case report

• One month prior to admission , he underwent a
  left percutaneous nephrolithotomy due to a
  staghorn stone .
• The postoperative period was normal and a
  nephrostogram after the procedure showed a normal
  urine flow with no evidence of a filling defect
  or extravasation.

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Case report

• A chest radiographic study obtained before
  discharge from the urology department showed no
  abnormalities

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Case report

• A few days after discharge , the patient
  started feeling shortness of breath on exertion .
• He was readmitted to the internal medicine
  department 26 days later because of orthopnea.

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Physical examination on presentation

• alert and oriented
• tachypneic with a respiratory rate of 30
  per min
• BP 147/84, PS 104 bpm
• temperature 36.2 C

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PHYSICAL EXAMINATION ON PRESENTATION

• Oxygen saturation 93 while breathing
• 5 L of oxygen by face mask
• Diminished breath sounds and dullness
• on percussion on the left side of chest
• 3 ankle edema
• The rest of examination revealed no
• abnormalities

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Case report

• Chest X-ray showed a large left pleural
  effusion that was found to be a transudate by
  thoracentesis

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Case report

• Treatment included oral furosemide and
  increasing doses of carvedilol , amlodipine and
  alfuzosin .
• No clinical improvement was noted in the
  initial 3 days of therapy .
• The treatment with ACE inhibitors that the
  patient was receiving was stopped because of
  deterioration in renal function.

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Case report

• An ultrasound examination on the second
  hospital day revealed a few simple cysts in both
  kidneys and left renal stones with suspected
  hydrocalics at the lower pole , but no
  hydronephrosis

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Case report

• An echocardiographic examination on the third
  hospital day showed a dilated left ventricle with
  severe dysfunction and generalized hypokinesis .
• A tentative diagnosis of severe congestive
  heart failure was made.

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Case report

• The patient was given furosemide
  intravenously for 5 additional days with
  gradually increasing doses and appropriate
  urinary output .
• Despite this diuretic regimen , the
  patients shortness of breath increased and a
  repeat chest X-ray showed the pleural effusion
  had become larger.

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Case report

• A repeat large-volume thoracentesis once
  again revealed a transudate with a creatinine
  level of 6 mg/dl and urea 204 mg/dl in the
  pleural fluid that were lower than in a
  simultaneous urine sample but higher than in
  plasma levels.
• Cytologic studies , Grams stain and cultures
  of the pleural fluid were negative.
• There wasnt nephrotic-range proteinuria.

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Case report

• The failure of furosemide treatment to
  alleviate the respiratory symptoms raised the
  suspicion that there was another cause of the
  pleural effusion .
• We speculated that the cause was related to
  the nephrolithotomy that the patient had
  undergone prior to admission to our department.

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Case report

• A renal perfusion scan was performed using
  DTPA ( 99 Tc-diethylene-triamine-pentaacetic
  acid) , which revealed urinary flow in the left
  pleural cavity .
• A diagnosis of the left reno-pleural fistula
  was made.

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99 Tc-DTPA - renal perfusion scan
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Case report

• A review of the nephrostogram that had been
  performed a month prior to admission to the
  internal medicine department this time revealed a
  pyeloureteral junction obstruction at the side of
  the urinothorax .
• The patient was transferred to the urology
  dpartment and underwent a left nephrostomy with
  immediate clinical improvement .

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Discussion

• reported causes of urinothorax are
• Urinary obstruction
• percutaneous renal and endoscopic
• ureteral interventions
• inflammatory or malignant process of
• the urinary tract
• blunt renal trauma
• shock wave lithotripsy and posterior urethral
• valve

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discussion

• To confirm urinothorax, it is necessary
• to perform thoracentesis in order to evaluate 3
  important diagnostic criteria
• (1) Transudative pleural fluid
• (2) Pleural fluid-serum creatinine ratio
• greater than 1.0 and
• (3) Low pleural fluid PH ( usually less than
  7.3),
• which is dependant on PH of the urine

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discussion

• The diagnosis of urinothorax requires a high
  index of suspicion .
• Most cases are diagnosed retrospectively when
  surgical revision of the obstruction results in a
  resolution of the pleural effusion .