Renal lymphangiectasia: One disease, many names!
The following case has been reported in the Indian Journal of Nephrology.

A 40-year-old female operated for uterine fibroid and endometriosis 2 years back presented with pain in bilateral flank and lower abdomen for the past 1 year. The clinical examination was normal except for mild tenderness in lower abdomen. Laboratory investigations revealed low hemoglobin (7.7 g/dl); however, total leukocyte counts were normal.

Patient had a previous ultrasound done outside, which suggested bilateral hydronephrosis due to mass effect of bulky uterus. Kidney function tests and urine examination were also normal. The patient subsequently underwent imaging to assess the cause of abdominal pain and distension.

Ultrasound examination of the abdomen demonstrated bilateral, almost symmetrical, multicystic fluid collections in the peripelvic spaces insinuating into the renal sinuses and splaying the bilateral pelvicalyceal system. Both kidneys were normal in size, shape and echo-texture with preserved corticomedullary differentiation and no evidence of hydronephrosis on either side. No cysts or masses were identified in other organs.

A contrast-enhanced CT of the abdomen revealed bilateral hypodense nonenhancing fluid attenuation collections with densities varying between 5 and 10 Hounsfield units in the peripelvic space. Both renal cortices showed normal enhancement with normal corticomedullary differentiation. No soft tissue or fat density masses were present within the fluid collections.

Delayed scans obtained after 15 min showed normal excretion, but splayed pelvicalyceal systems due to intervening fluid collections within the sinuses. There was no hydronephrosis on either side. Renal arteries and veins were showing normal contrast enhancement with splaying of the pelvic vasculature.

Subsequent MRI confirmed the CT findings of multicystic collections in bilateral peripelvic spaces consistent with renal pelvic lymphangiectasia.

Key takeaways:-
- The differential diagnosis of renal lymphangiectasia includes hydronephrosis, polycystic kidney disease, urinoma, and lymphoma.

- Excretory urography is confirmatory for hydronephrosis, which shows excretion of contrast into the pelvicalyceal system.

- Adult polycystic kidney disease demonstrates varying size scattered intra-parenchymal cysts, and associated liver and pancreatic cysts.

- The diagnosis of renal lymphangiectasia is usually made confidently on imaging, as in this case. Aspiration is usually not required but in atypical cases, when done, shows chylous fluid.

- Treatment is usually not necessary as these lesions may regress spontaneously.

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