Published online Dec 26, 2020. doi: 10.12998/wjcc.v8.i24.6330
Peer-review started: June 26, 2020
First decision: September 24, 2020
Revised: October 1, 2020
Accepted: November 4, 2020
Article in press: November 4, 2020
Published online: December 26, 2020
The renal system has a specific pleural effusion associated with it in the form of “urothorax”, a condition where obstructive uropathy or occlusion of the lymphatic ducts leads to extravasated fluids (urine or lymph) crossing the diaphragm via innate perforations or lymphatic channels. As a rare disorder that may cause pleural effusion, renal lymphangiectasia is a congenital or acquired abnormality of the lymphatic system of the kidneys. As vaguely mentioned in a report from the American Journal of Kidney Diseases, this disorder can be caused by extrinsic compression of the kidney secondary to hemorrhage.
A 54-year-old man with biopsy-proven acute tubulointerstitial nephropathy experienced bleeding 3 d post hoc, which, upon clinical detection, manifested as a massive perirenal hematoma on computed tomography (CT) scan without concurrent pleural effusion. His situation was eventually stabilized by expeditious management, including selective renal arterial embolization. Despite good hemodialysis adequacy and stringent volume control, a CT scan 1 mo later found further enlargement of the perirenal hematoma with heterogeneous hypodense fluid, left side pleural effusion and a small amount of ascites. These fluid collections showed a CT density of 3 Hounsfield units, and drained fluid of the pleural effusion revealed a dubiously light-colored transudate with lymphocytic predominance (> 80%). Similar results were found 3 mo later, during which time the patient was free of pulmonary infection, cardiac dysfunction and overt hypoalbuminemia. After careful consideration and exclusion of other possible causative etiologies, we believed that the pleural effusion was due to the occlusion of renal lymphatic ducts by the compression of kidney parenchyma and, in the absence of typical dilation of the related ducts, considered our case as extrarenal lymphangiectasia in a broad sense.
As such, our case highlighted a morbific passage between the kidney and thorax under an extraordinarily rare condition. Given the paucity of pertinent knowledge, it may further broaden our understanding of this rare disorder.
Core Tip: It is known that obstructive uropathy or occlusion of the lymphatic ducts may lead to extravasated fluids (urine or lymph) crossing the diaphragm via innate perforations or lymphatic channels. Therein, this clinical phenomenon is addressed as the “urothorax”. Among the diverse etiologies, renal lymphangiectasia is a congenital or acquired abnormality of the lymphatic system of the kidneys. Under this instance, pleural effusion of lymphoid origin may develop when the renal parenchyma is tightly compressed by a perirenal hematoma. Arguably, tight compression of the renal parenchyma may keep the draining lymphatic vessels shut but not prevent the inflow from the capsular lymph plexus. Thus, our report has for the first time described this extremely rare scenario and raises clinical awareness of the underlying passage, through which upward spread of perirenal infection could result in lung abscess.