Ann Thorac Surg 1995;60:687-689
© 1995 The Society of Thoracic Surgeons
Case Report
Thoracic Aneurysm as a Cause of Chyluria: Resolution by Surgical Treatment
Pilar Garrido, MD,
Ramon Arcas, MD,
Jaime F. Bobadilla, MD,
Jose Albertos, MD,
Jose M. González Santos, MD,
Jose L. Vallejo, MD, PhD,
Emilia Bastida, MD
Departments of Cardiovascular Surgery, Cardiology, and Anesthesiology, Hospital Gregorio Marañón, Madrid, Spain
Accepted for publication February 23, 1995.
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Abstract
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A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.
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Introduction
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Chyluria is defined as the presence of lymph or chyle in the urine. The high concentration of chylomicrons give the urine its typical milky appearence. Chyluria is due to an obstruction or stenosis of the thoracic duct caused by parasitic infections, most commonly filariasis, and occasionally to trauma and malignant diseases [1]. This report presents an extremely unusual cause of chyluria: a posttraumatic thoracic aneurysm, which was successfully treated by surgical repair.
A 37-year-old farmer, who fell from a farm tractor without apparent consequences, started to have whitish urine 1 year later. He remained symptomatic for the next 2 years, and then consulted a physician. No other symptoms were present, and physical examination was unremarkable; there was no edema or loss of body weight. Twenty-four–hour urinary studies showed proteinuria and lipiduria. Cytoscopic examination demonstrated chyle in the urine. Chest roentgenography showed dilatation of the aortic arch. Urography and abdominal computed tomographic scan were normal. Thoracic computed tomographic scan and aortography demonstrated the presence of an aneurysm in the upper descending thoracic aorta (Fig 1
). Lymphography confirmed the compression of the thoracic duct by the aneurysm, without other lymphatic pathology (Fig 2). Operation through a left posterolateral thoracotomy revealed a 7-cm-long pseudoaneurysm beyond the origin of the left subclavian artery, which compressed the thoracic duct. After 25 minutes of aortic cross-clamping, the aneurysmatic zone was replaced by a no. 20 woven double-velour graft (Hemashield; Meadox Medicals, Oakland, NJ) without postoperative complications. During a 3-year follow-up, the patient has remained asymptomatic, with no further chyluria.
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Fig 1. . The aortogram (A, lateral view; B, frontal view) shows an aneurysm that begins just beyond the left subclavian artery. The aneurysm extends to the distal portion of the aortic arch.
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Fig 2. . Lymphography revealed the compression of the thoracic duct by the aneurysm with tortuosity; there is no other lymphatic pathology.
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Comment
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Chyluria occurs after rupture of lymphatic vessels into the renal tubules due to high lymphatic pressure caused by an obstruction or stenosis of the major lymphatic duct [2]. This obstruction, which may be congenital or acquired, is most commonly caused by filariasis, a Wuchereria bancrofti infection. Other parasitic infections, such as Taenia echinococcus, Ascaris lumbricoides, or Schistosoma mansoni, and nonparasitic infections such as tuberculosis may also cause chyluria. Infrequent causes are trauma, retroperitoneal tumors or lymphangiectasy, mesenteric adenitis, pelvic lipomatosis [1], and abdominal or thoracic operation [3, 4]. Depending on the lymphatic area affected, either chyluria, chylopericardium [5], chylothorax [6], or, more frequently, chylous ascitis may occur [3, 4, 7]. There are some cases of unknown origin [8].
We report an unusual case of chyluria due to compression of the thoracic duct by a pseudoaneurysm of the thoracic aorta. Chyluria may be intermittent or continuous. In this case it was nocturnal, probably because of a higher degree of compression caused by lying down.
The usual diagnostic procedures were performed. Parasitic and nonparasitic infection were ruled out. Urography and abdominal computed tomographic scan were normal. Chest roentgenogram showed aortic dilatation. Thoracic computed tomography and aortography demonstrated the presence of an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. In some cases, conservative treatment, including rest and a diet rich in middle-chain triglycerides, may be effective. Surgical procedures may include a lymphatic-venous fistula in one of the lower extremities or the Gerota fascia scission [1]. In this case surgical repair of the aorta was performed. The aneurysmatic zone was replaced by a synthetic tube graft. After the operation, chyluria was no longer present.
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Footnotes
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Address reprint requests to Dr Garrido, Department of Cardiovascular Surgery, Hospital Gregorio Marañón, Doctor Esquerdo 46, Madrid 28007, Spain.
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References
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- Oudkerk Pool M, Van Der Hem KG, Stel HV, Luth WJ, Rasker FM, Gans RO. Bilateral excision of perinephric fat and fascia (Gerota's fasciectomy) in the treatment of intratactable chyluria. J Urol1991;146:1374–6.[Medline]
- Stalens JP, Falk M, Howmann-Giles R, Roy LP. Milky urine. A child with chyluria. Eur J Pediat1992;151:61–2.[Medline]
- Williams RA, Vetto J, Quinones-Baldrich W, Bongard FS, Wilson SE. Chylous ascites following abdominal aortic surgery. Ann Vasc Surg1991;5:247–52.[Medline]
- Ablan CK, Littooy FN, Freeark RJ. Postoperative chylous ascites: diagnosis and treatment. A series report and literature review. Arch Surg 1990;125:270–3.[Abstract/Free Full Text]
- Matsuda H, Hosokawa Y, Okada M, Nakamura K. Successful surgical treatment of primary chylopericardium in infant. A usefulness of intraoperative thoracic ductgraphy. Nippon Kyoby Geba Gakkai Zasshi1991;39:1765–70.
- Grant PW, Brown SW. Traumatic chylothorax: a case report. Aust N Z J Surg1991;61:798–800.[Medline]
- Krol-van-Straaten MJ, Terpstra WE, De-Maat CE. Infected aneurysm of the abdominal aorta due to Listeria monocytogenes. Neth J Med1991;38:254–6.[Medline]
- Kropp R, Schutz I, Weis E. Bilateral chylotorax. Case report and literature review. Pneumologie1991;45:1004–9.[Medline]
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A. Guermazi, P. Brice, C. Hennequin, and E. Sarfati
Lymphography: An Old Technique Retains Its Usefulness
RadioGraphics,
November 1, 2003;
23(6):
1541 - 1558.
[Abstract]
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Abstract
Introduction
