Urine in the lung: An uncommon cause of transudative pleural
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A 93-year-old man with past medical history significant for chronic kidney disease stage 4, sick sinus syndrome status post permanent pacemaker placement, type 2 diabetes mellitus, adenocarcinoma of the prostate status post brachytherapy complicated by proctitis, high grade transitional cell carcinoma of the right kidney with right hydronephrosis, and recurrent hematuria was hospitalized for worsening hematuria and suprapubic pain. Home medications at the time of presentation included furosemide 40 mg daily.

The patient was afebrile and hemodynamically stable. Clinical exam revealed gross hematuria requiring continuous bladder irrigation and he had decreased breath sounds on the right. Chest radiograph (CXR) showed a moderate to large right pleural effusion. (CT) of the abdomen and pelvis illustrated moderate to severe right-sided hydronephrosis and hydroureter with a heterogeneous density within the right renal pelvis and diffuse mural thickening in the posterior and right lateral urinary bladder walls. An ultrasound guided thoracentesis was performed the following day with the removal of 2 L of clear yellow fluid. Serum creatinine was 2.59mg/dL resulting in a pleural fluid to serum creatinine ratio of 0.96. Of note, the serum creatinine was 2.34 mg/dL the following morning.

He underwent cystoscopy with transurethral resection of bladder mucosal abnormality posteriorly, bilateral retrograde ureteropyelograms with right ureteral stent placement, and visual internal urethrotomy of bulbomembranous urethra in very close proximity to the external striated sphincter. Unfortunately, despite these interventions a renal ultrasound showed persistent dilation of the right renal collecting system with hypoechoic material within the system concerning for combination of solid mass and hemorrhage.

A repeat thoracentesis was performed ten days later, yielding 1.85 L of clear yellow fluid. Pleural fluid creatinine and serum creatinine were 4.1 mg/dl and 3.94 mg/dL respectively, supporting the diagnosis of urinothorax with a pleural to serum creatinine ratio of 1.04. The patient declined further urologic or oncologic interventions, opting for indwelling right pleural catheter placement and was transitioned to a skilled nursing facility.

source: https://www.sciencedirect.com/science/article/pii/S2213007120304342?dgcid=rss_sd_all
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