Case Report
Urinothorax Secondary to Bilateral Rupture of the Ureters: An Unusual Case of Pleural Exudate
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A well-defined pleural-based calcified mass in the upper zone of the right lung. (b) Coronal CT section in mediastinal window. The mass is observed in soft tissue density with a calcified pleural base (red arrow). In addition, it is observed that the inferior vena cava continues in the thorax as the azygos vein (red asterisk). (c) Coronal MinIP image. Two hypoarterial main bronchi branching from the trachea are observed. (d) Polyplenism is observed in the left upper quadrant of the abdomen. (e) Opening of hepatic veins directly into the left atrium is observed. (f) Right atrial appendage is observed in left atrial appendage morphology (red asterisk).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hüseyin Alper Kızıloğlu" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Hüseyin Alper" "apellidos" => "Kızıloğlu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001047?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000006/v2_202308080837/S0300289623001047/v2_202308080837/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289623001023" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.02.020" "estado" => "S300" "fechaPublicacion" => "2023-06-01" "aid" => "3283" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2023;59:387-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "A Red Herring to Iatrogenic Pneumothorax" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "387" "paginaFinal" => "388" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1594 "Ancho" => 2841 "Tamanyo" => 388372 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Posteroanterior chest radiograph showing grade I pneumothorax in the right lung apex. (b) Follow-up chest radiograph showing complete resolution of the pneumothorax 10 days later. (c) EMG needle used in the examination of the serratus anterior muscle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Natalia Beatriz Mena Casado, Manuel Cuesta Martín" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Natalia Beatriz" "apellidos" => "Mena Casado" ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "Cuesta Martín" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001023?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000006/v2_202308080837/S0300289623001023/v2_202308080837/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Urinothorax Secondary to Bilateral Rupture of the Ureters: An Unusual Case of Pleural Exudate" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "389" "paginaFinal" => "390" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Almudena González-Montaos, Iván Rodríguez-Otero, Elena Chávarri-Ibáñez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Almudena" "apellidos" => "González-Montaos" "email" => array:1 [ 0 => "almudena.gonzalez.montaos@sergas.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Iván" "apellidos" => "Rodríguez-Otero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Elena" "apellidos" => "Chávarri-Ibáñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pneumology Department, Álvaro Cunqueiro Hospital, Vigo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neumo I + i, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Radiology Department, Álvaro Cunqueiro Hospital, Vigo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1911 "Ancho" => 2500 "Tamanyo" => 310136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Right pleural effusion (red arrow), contrast extravasation related to rupture of both ureters and formation of the two urinomas, the right one being more evident (white arrow); bladder balloon.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">88-Year-old man, with a history of prostatic hyperplasia who had abandoned treatment, consulted for dyspnea, dry cough and right pleuritic chest pain in the last 3 days, as well as decreased diuresis. At the initial evaluation he was stable, with blood pressure 133/83, 95<span class="elsevierStyleHsp" style=""></span>bpm, 37<span class="elsevierStyleHsp" style=""></span>°C and SaO<span class="elsevierStyleInf">2</span> 93%, without breath sounds in the right lung and a suprapubic mass painful on palpation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Chest X-ray revealed a right unilateral moderate pleural effusion. Blood test showed impaired kidney function and increased acute phase reactants (creatinine: 3.16<span class="elsevierStyleHsp" style=""></span>mg/dL; C-reactive protein: 152<span class="elsevierStyleHsp" style=""></span>mg/L).</p><p id="par0015" class="elsevierStylePara elsevierViewall">A thoracentesis was performed obtaining a yellowish pleural fluid. Its analysis showed a mononuclear exudate: glucose 149<span class="elsevierStyleHsp" style=""></span>mg/dL; total protein 3.6<span class="elsevierStyleHsp" style=""></span>g/dL; albumin 2.5<span class="elsevierStyleHsp" style=""></span>g/dL; LDH 286<span class="elsevierStyleHsp" style=""></span>IU/L, pH 7.35; pleural fluid/serum protein ratio 0.6; pleural fluid/serum LDH ratio 1.56. A 1500<span class="elsevierStyleHsp" style=""></span>ml chest drain was also performed improving the symptoms, although only partially. CT revealed a still large right pleural effusion with no evidence of underlying pulmonary or diaphragmatic pathology. Likewise, a bladder balloon and a rupture of both ureters with contrast extravasation and formation of urinomas bilaterally, greater on the right, were evidenced, with discreet hyper-uptake of both ureters in relation to urethritis, as well as a notable increase in prostate size (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Bladder catheterization demonstrated significant urinary retention. A second thoracentesis was performed to extend the analysis after the radiological findings. The pleural fluid obtained showed creatinine 3.17<span class="elsevierStyleHsp" style=""></span>mg/dL, urea 155<span class="elsevierStyleHsp" style=""></span>mg/dL, pleural fluid/serum creatinine ratio >1, confirming urinothorax. Culture and cytology of the pleural fluid were negative. A percutaneous nephrostomy was initially proposed but was not possible since no significant hydronephrosis was identified by ultrasound after bladder catheterization. Conservative management was adopted with favorable evolution. A control CT was performed without evidence of ureteral damage or urinomas, with persistence of minimal pleural effusion. Treatment for prostatic hyperplasia with an alpha-blocker was reinstated and prostatic surgery was proposed to the patient at discharge.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Urinothorax is a rare presentation of pleural effusion, until a 2017 review only 88 cases had been registered.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Respiratory symptoms are non-specific and depending on the cause, which is usually traumatic or obstructive on the urinary tract, abdominal pain or urinary symptoms may appear.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> Among the obstructive causes, prostate pathology is the most frequent, although lithiasis or malignancy have been described.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Other etiologies are surgery and gynecological pathology.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It is usually ipsilateral to urinary injury<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> and urine migration toward the pleura is often through lymphatic drainage or diaphragmatic permeability.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> The diagnosis is established by a pleural fluid similar to urine with pleural/plasma creatinine ratio >1.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> pH use to be <7.40 but in the presence of hematuria or infections may become alkaline.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> It is typically a transudate,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> but there are cases of exudate<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> due to high LDH concentrations after cell disruption.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> Over time it becomes similar to serum, so early suspicion is necessary to increase diagnostic sensitivity.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Treatment consists of relieving respiratory symptoms, where chest drainage can be helpful but is often insufficient, and management of the underlying cause.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1911 "Ancho" => 2500 "Tamanyo" => 310136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Right pleural effusion (red arrow), contrast extravasation related to rupture of both ureters and formation of the two urinomas, the right one being more evident (white arrow); bladder balloon.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urinothorax: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.E. Toubes" 1 => "A. Lama" 2 => "L. Ferreiro" 3 => "A. Golpe" 4 => "J.M. Álvarez-Dobaño" 5 => "F.J. González-Barcala" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/jtd.2017.04.22" "Revista" => array:6 [ "tituloSerie" => "J Thorac Dis" "fecha" => "2017" "volumen" => "9" "paginaInicial" => "1209" "paginaFinal" => "1218" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28616270" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The urinothorax: a comprehensive review with case series" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Austin" 1 => "S.N. Jogani" 2 => "P.B. Brasher" 3 => "R.G. Argula" 4 => "J.T. Huggins" 5 => "A. Chopra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjms.2017.03.034" "Revista" => array:6 [ "tituloSerie" => "Am J Med Sci" "fecha" => "2017" "volumen" => "354" "paginaInicial" => "44" "paginaFinal" => "53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28755732" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urinothorax: a new approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Garcia-Pachon" 1 => "S. Romero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.mcp.0000230628.65515.86" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Pulm Med" "fecha" => "2006" "volumen" => "12" "paginaInicial" => "259" "paginaFinal" => "263" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16825877" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urinothorax as an unusual type of pleural effusion – case report and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.G. Ferreira" 1 => "F. Furriel" 2 => "A.J. Ferreira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rppnen.2013.02.001" "Revista" => array:5 [ "tituloSerie" => "Rev Port Pneumol (Engl Ed)" "fecha" => "2013" "volumen" => "19" "paginaInicial" => "80" "paginaFinal" => "83" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urinotórax: ¿siempre un trasudado pleural?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Sancho Calvache" 1 => "X. Pomares Amigó" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1157/13119946" "Revista" => array:5 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2008" "volumen" => "44" "paginaInicial" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18448022" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005900000006/v2_202308080837/S0300289623001035/v2_202308080837/en/main.assets" "Apartado" => array:4 [ "identificador" => "93562" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005900000006/v2_202308080837/S0300289623001035/v2_202308080837/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001035?idApp=UINPBA00003Z" ]
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