1975, British Journal of Radiology, 48, 685-686
AUGUST 1975
Case reports FIG. 4. Same retrograde thoracic aortogram in a later phase demonstrates the dilated anomalous right subclavian artery.
with no history of pain, possibly due to slow progression of the aortic dissection. The underlying pathology in our patient was arteriosclerosis and cystic medial necrosis of the aorta. Her race and hypertension were predisposing factors, although dissection may well have antedated hypertension. With the exception of sudden right femoral artery occlusion, there were no symptoms suggesting aortic dissection. The radiographic presentation seen on admission chest film is most unusual for aortic dissection and we cannot find an example of an identical plain radiographic appearance in the literature. REFERENCES DEBAKEY, M. E., BEALL, A. C , Jun., COOLEY D. A., CRAWFORD, E. S., MORRIS, G. C , 1966. Dissecting
anuerysms of the aorta; Surgical Clinics of North America, 4,1045-1055. HIRST, A. E., Jun., JOHNS, V. J., Jun., KIME, S. W. Jun.,
1958. Dissecting aneurysm of the aorta; A review of 505 cases. Medicine 37; 217-279. O'DONOVON, T. P. B., OSMUNDSON, P. J., and PAYNE, W.
S., 1964. Painless dissecting aneurysm of the aorta. Circulation, 29, 782-786.
Urinothorax—an unusual pleural effusion By L B. Barek, M.D., and O. S. Cigtay, M.D. Department of Radiology, Georgetown University Hospital, Washington, D.C. {Received September, 1974) Post-operative pleural effusions are not uncommon. The aetiologies of these effusions are often apparent to the clinician. This case presents an unusual cause for the pleural effusion, that is, extravasation of urine from the peritoneum and retroperitoneal space into the thoracic cavity. Case history A 47-year-old white female presented with a sub-mucous aborting fibroid with severe menorrhagia. Pre-operative urography showed a congenital absence of the right kidney and collecting system. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The right ovary was noted to be a streak ovary. In the recovery room the patient's urinary output was noted to be unsatisfactory in spite of adequate hydration. An intravenous urogram showed non-visualization on the left side. A retrograde pyelogram was performed and showed extravasation of opaque material along the drain on the left side of the bladder and distal ureter (Fig. 1). At this time a chest film revealed a left pleural effusion. At re-exploration an obstructed left ureter and a laceration of the
bladder were found. Urine was noted in the peritoneal cavity and retroperitoneal spaces. Drains were placed in the retroperitoneal space and peritoneal cavity. In addition, a drain was inserted in the left ureter and a supra-pubic drain was placed in the bladder. The post-operative chest films again revealed the presence of a large left pleural effusion (Fig. 2). Thoracentesis revealed the pleural fluid to be urine. With continued satisfactory drainage to the left kidney and bladder, the pleural effusion cleared. Renal function remained normal throughout the hospital course. The patient was discharged in satisfactory condition with a suprapubic drain in place eleven days after the corrective surgery. DISCUSSION
Urinothorax is an uncommon aetiology for pleural effusion. Friedland, Axman, and Love (1971) reported urinothorax in a neonate as a complication of posterior urethral valves. In addition, Corriere, Miller and Murphy (1968) described two cases of right-sided pleural effusions in patients with
685
VOL.
48, No. 572 Case reports
FIG. 2. Supine chest film demonstrating large left pleural effusion.
FIG. 1. Ten-minute drainage film demonstrating extravasation from middle-calyces and in the pelvi-ureteric region. There is also contrast coating the surgical drain.
hydronephrosis but the nature of the pleural effusion in their cases was not ascertained. In all cases, as in our patient, the pleural effusions cleared after adequate drainage. The mechanism for the urine finding its way into the pleural cavity is unknown. Two theories have been proposed by Friedland et al. They are: (1) Direct leakage into the mediastinum and then rupture into the pleural space. (2) Drainage via lymphatics. Corriere et al. (1968) proposed the lymphatic drainage as the mechanism of effusion in their cases. They noted that when a ureter is occluded, partially or totally, the lymphatic drainage of the kidney increases. In man, when an obstructive kid-
ney is exposed surgically, there is always marked perirenal oedema in the retroperitoneal tissue. In adults as well as neonates urinary ascites has been well described with obstructive uropathy. Lemon and Higgins (1929) reported the lymphatic absorption of particulate matter through the normal and paralysed diaphragm. In their experiments they demonstrated that there were lymphatic connections between the diaphragm and lymph nodes in the region of the kidney. In the case discussed in this paper, there was no evidence of fluid within the mediastinum suggesting that the lymphatic drainage may have been the aetiology for the urinothorax. In patients with urinary obstruction who developed pleural effusion, the possibility of urinothorax should be considered as an unusual aetiology for the development of the effusion. REFERENCES CORRIERE, J. N., MILLER, W. T., and MURPHY, J. J.,
1968.
Hydronephrosis as a cause of pleural effusion. Radiologv, 90,79-84.
FRIEDLAND, G. W., AXMAN, M. M., and LOVE, T., 1971.
Neonatal "urinothorax" associated with posterior urethral valves. British Journal of Radiology, 44, 471-474. LEMON, W. S., and HIGGINS, G. M., 1929. Lymphatic
686
absorption of particulate matter through normal and paralysed diaphragm: An experimental study. American Journal of Medical Science, 178, 536-547.
AUGUST 1975
Case reports FIG. 4. Same retrograde thoracic aortogram in a later phase demonstrates the dilated anomalous right subclavian artery.
with no history of pain, possibly due to slow progression of the aortic dissection. The underlying pathology in our patient was arteriosclerosis and cystic medial necrosis of the aorta. Her race and hypertension were predisposing factors, although dissection may well have antedated hypertension. With the exception of sudden right femoral artery occlusion, there were no symptoms suggesting aortic dissection. The radiographic presentation seen on admission chest film is most unusual for aortic dissection and we cannot find an example of an identical plain radiographic appearance in the literature. REFERENCES DEBAKEY, M. E., BEALL, A. C , Jun., COOLEY D. A., CRAWFORD, E. S., MORRIS, G. C , 1966. Dissecting
anuerysms of the aorta; Surgical Clinics of North America, 4,1045-1055. HIRST, A. E., Jun., JOHNS, V. J., Jun., KIME, S. W. Jun.,
1958. Dissecting aneurysm of the aorta; A review of 505 cases. Medicine 37; 217-279. O'DONOVON, T. P. B., OSMUNDSON, P. J., and PAYNE, W.
S., 1964. Painless dissecting aneurysm of the aorta. Circulation, 29, 782-786.
Urinothorax—an unusual pleural effusion By L B. Barek, M.D., and O. S. Cigtay, M.D. Department of Radiology, Georgetown University Hospital, Washington, D.C. {Received September, 1974) Post-operative pleural effusions are not uncommon. The aetiologies of these effusions are often apparent to the clinician. This case presents an unusual cause for the pleural effusion, that is, extravasation of urine from the peritoneum and retroperitoneal space into the thoracic cavity. Case history A 47-year-old white female presented with a sub-mucous aborting fibroid with severe menorrhagia. Pre-operative urography showed a congenital absence of the right kidney and collecting system. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The right ovary was noted to be a streak ovary. In the recovery room the patient's urinary output was noted to be unsatisfactory in spite of adequate hydration. An intravenous urogram showed non-visualization on the left side. A retrograde pyelogram was performed and showed extravasation of opaque material along the drain on the left side of the bladder and distal ureter (Fig. 1). At this time a chest film revealed a left pleural effusion. At re-exploration an obstructed left ureter and a laceration of the
bladder were found. Urine was noted in the peritoneal cavity and retroperitoneal spaces. Drains were placed in the retroperitoneal space and peritoneal cavity. In addition, a drain was inserted in the left ureter and a supra-pubic drain was placed in the bladder. The post-operative chest films again revealed the presence of a large left pleural effusion (Fig. 2). Thoracentesis revealed the pleural fluid to be urine. With continued satisfactory drainage to the left kidney and bladder, the pleural effusion cleared. Renal function remained normal throughout the hospital course. The patient was discharged in satisfactory condition with a suprapubic drain in place eleven days after the corrective surgery. DISCUSSION
Urinothorax is an uncommon aetiology for pleural effusion. Friedland, Axman, and Love (1971) reported urinothorax in a neonate as a complication of posterior urethral valves. In addition, Corriere, Miller and Murphy (1968) described two cases of right-sided pleural effusions in patients with
685
VOL.
48, No. 572 Case reports
FIG. 2. Supine chest film demonstrating large left pleural effusion.
FIG. 1. Ten-minute drainage film demonstrating extravasation from middle-calyces and in the pelvi-ureteric region. There is also contrast coating the surgical drain.
hydronephrosis but the nature of the pleural effusion in their cases was not ascertained. In all cases, as in our patient, the pleural effusions cleared after adequate drainage. The mechanism for the urine finding its way into the pleural cavity is unknown. Two theories have been proposed by Friedland et al. They are: (1) Direct leakage into the mediastinum and then rupture into the pleural space. (2) Drainage via lymphatics. Corriere et al. (1968) proposed the lymphatic drainage as the mechanism of effusion in their cases. They noted that when a ureter is occluded, partially or totally, the lymphatic drainage of the kidney increases. In man, when an obstructive kid-
ney is exposed surgically, there is always marked perirenal oedema in the retroperitoneal tissue. In adults as well as neonates urinary ascites has been well described with obstructive uropathy. Lemon and Higgins (1929) reported the lymphatic absorption of particulate matter through the normal and paralysed diaphragm. In their experiments they demonstrated that there were lymphatic connections between the diaphragm and lymph nodes in the region of the kidney. In the case discussed in this paper, there was no evidence of fluid within the mediastinum suggesting that the lymphatic drainage may have been the aetiology for the urinothorax. In patients with urinary obstruction who developed pleural effusion, the possibility of urinothorax should be considered as an unusual aetiology for the development of the effusion. REFERENCES CORRIERE, J. N., MILLER, W. T., and MURPHY, J. J.,
1968.
Hydronephrosis as a cause of pleural effusion. Radiologv, 90,79-84.
FRIEDLAND, G. W., AXMAN, M. M., and LOVE, T., 1971.
Neonatal "urinothorax" associated with posterior urethral valves. British Journal of Radiology, 44, 471-474. LEMON, W. S., and HIGGINS, G. M., 1929. Lymphatic
686
absorption of particulate matter through normal and paralysed diaphragm: An experimental study. American Journal of Medical Science, 178, 536-547.
