Vol. 117, Nia::·ch
'THE Jo--:JRNi1.L 0F UR.OLO-G-Y
C8pyright © 1977 by r_rhe
CASE REPORT AND BRIEF LITF:RATURE REVIEvV
JOHN \V. KLOUSIA, BRUCE L. MCCLENNAN
HRANT S. SEMERJIAN
From the Departments of Urology and Radiology, George Washington U niuersity, Washington, D. C.
A case of chyluria presumably caused by Filaria bancrofti is presented. The radiographic and urologic presentation as well as a brief review of the natural history, diagnosis and treatment is included. Chyluria, the passage of lymphatic fluid in the urine, is almost always caused by filarial infection leading to subsequent lymphatic obstruction and reflux. The influx of refugees from endemic areas may well increase its prevalence in this country. Herein we report a case of chyluria in a Vietnamese refugee.
majority of cases of parasitic chyluria. Other parasites incriminated include Echinococcus, Cysticercus cellulosae, Ascaris lumbricoides, tinea vera and nana, Cercomonas hominis as well as pacifica and malayi filariasis.1.:i Bancroft's filariasis can be divided into 3 stages; subclinical (incubation), acute (fever and lymphangioadenitis) and chronic (elephantiasis, adenopathy and chyluria). 4 The filariae are the cause of fibrous obliteration of the lymph vessels resulting in lymphatic varices. 5 Rupture of lymphatic varices into the urinary system is the cause of chyluria. 2 In cases of lymphatic obstruction rupture also may occur into the intestines and pleural or peritoneal cavity. r; The incidence of detectable chyluria among patients with filariasis is 1 to 2 per cent. 4 ' 7 The age distribution ranges from 17 months to more than 70 years. 2 The interval from the acute stage of filarial
B. T., a 59-year-old Vietnamese woman, had lived in North and South Vietnam prior to her arrival in the United States. Aside from urinary complaints her health had been excellent. The patient first noticed the onset of painless pink colored urine 30 years ago, 6 weeks after the birth of the fifth of her 8 children. This symptom resolved spontaneously and since that time she had had many similar episodes lasting from days to several weeks. During one 3-month episode she suffered transient weight loss and anemia. No formal urologic studies had been done prior to the present hospitalization. The patient exhibited intermittent gross hematochyluria (part A of figure). Physical examination was unremarkable. Complete blood count revealed a white count of 9,100, hemoglobin 11.3 gm. per 100 ml. and hematocrit 36.2 per cent with an eosinophil count of23 per cent. Routine blood analyses were within normal limits. Urine samples analyzed for lipid, albumin, fibrinogen and lymphocytes were intermittently positive. Stool examination for ova and parasites was positive for Strongyloides. Multiple blood smears, urine collections, Knott's concentration and membrane filter techniques were negative for filaria. An excretory urogram and cystoscopy were unremarkable. Lymphangiography revealed dilated tortuous lymphatics surrounding the right kidney with obstruction of lymphatic flow above that level (part B of figure). The patient was started on a course of diethylcarbamazine for the Strongyloides. A severe allergic reaction occurred 4 later. The medication was discontinued since the stools was free of symptoms. She was for as an uu,cuauLe.u
A, specimens of normal and chylous urine. B, lyn1phangiogram reveals abnormal renal lymphatics. -
Chyluria is a of an ~.1 6 Ylu,r disease process, which must be distinguished from other entities that create a similarly turbid urine, including pyuria, degeneration from a caseating tuberculous cavity and lipiduria. 1 Lipiduria may be secondary to fat embolism, diabetic neuropathy, degenerating tumors of the kidney and certain nephrotoxins. 2 The diagnosis of true chyluria may be established by the simultaneous presence of fat and lymphocytes in the urine. 1 Chyluria is divided into parasitic and non-parasitic varieties. Non-parasitic causes include congenital lymphatic malformation, traumatic lymphatico-urinary fistula and lymphatic obstruction caused by trauma, tuberculosis, abscess or neoplasm. Infestation by Wuchereria bancrofti causes the vast Accepted for publication October 8, 1976.
infestation to the onset of has been reported from l month to 54 years. 8 The presenting symptoms, in addition to milky urine, are backache, ureteral colic from clot passage or other concomitant symptoms of late stage filarial disease, that is elephantiasis, asthma and so forth. In prolonged cases weight loss, anemia and general debilitation may be present. 8 The disease is most often intermittent in nature with exacerbations traced to pregnancy physical exertion, menstruation and trauma. Occasionally, the recumbent position may relieve the process. The most important point to be emphasized in the natural course of this disease is the intermittent and benign nature of the chyluria. After establishing the chylous nature of the urine an attempt must be made to delineate the fistulous lymphatico-urinary connection. This may be unilateral or bi-
KLOUSIA, MCCLENNAN AND SEMERJIAN
lateral and usually is demonstrated with either lymphangiography or pyelography. 4 , 8 In a majority of the cases conservative management with a low fat diet and high fluid intake will adequately relieve the symptoms. Several modes of surgical intervention have been proposed for the persistent or debilitating case. Because of the relapsing nature of chyluria all modes of therapy are difficult to evaluate. Various sclerosing solutions introduced into the renal pelvis have been proposed. Yamauchi, in an extensive review of the literature, recommends a 1 to 2 per cent silver nitrate solution on alternating days until the urine is clear. 8 In 1962 Torres and Estrada reported 2 successful cases of surgical capsulectomy and stripping ofrenal pedicle lymphatics. 9 More recently, Koo and Van Langenberg reported a 3-year followup of 8 cases of pedicle stripping and ligation, with success in 7. 1 However, they mention the possibility of decompressing the lymphatic system by diverting it into the venous system, particularly in bilateral disease. This may become the procedure of choice since it preserves the safety valve effect, which the renal lymphatics may exhibit in relieving the back pressure of renal obstruction. 10
1. Koo, C. G. and Van Lengenberg, A.: Chyluria. A clinical study.
J. Roy. Coll. Surg., 14: 31, 1969. 2. Johnston, D. W.: Chyluria: case report and review of literature.
Ann. Intern. Med., 42: 931, 1955. 3. Wiggelinkhuizen, J., Landman, D. and Greenberg, E.: Chylu-
ria. Amer. J. Dis. Child., 124: 99, 1972. 4. Akisada, M. and Tani, S.: Filarial chyluria in Japan. Lymphography, etiology, and treatment in 30 cases. Radiology, 90: 311,
1968. 5. Swanson, G. E.: Lymphangiography in chyluria. Radiology, 81: 473, 1963. 6. Servelle, M., Turiaf, J., Rouffilange, H., Scherer, G., Perrot, H., Frentz, F. and Turpyn, H.: Chyluria in abnormalities of the thoracic duct. Surgery, 54: 536, 1963. 7. Ray, P. N. and Rao, S. S.: Chyluria of filarial origin. Brit. J. Urol., 11: 48, 1939. 8. Yamauchi, S.: Chyluria: clinical, laboratory and statistical study of 45 personal cases observed in Hawaii. J. Urol., 54: 318, 1945. 9. Torres, L. F. and Estrada, J., Jr.: Experiences in the treatment of chyluria. J. Urol., 87: 73, 1962. 10. Kaufman, J. J. and Goodwin, W. E.: Renal lymphatics. III. Clinical implications and experiments of nature. Ann. Intern. Med., 49: 109, 1958.