Pleural effusion and ascites in extrarenal lymphangiectasia caused by post-biopsy hematoma: A case report

Abstract

Background: 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.

Case summary: 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.

Conclusion: 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.

Keywords: Case report; Lymphatic drainage; Perirenal hematoma; Pleural effusion; Renal lymphangiectasia; Urothorax.

Figure 1

Evolution of the perirenal hematoma, pleural effusion and ascites in parallel with the corresponding serum creatinine and plasma albumin. Upper panel: Values of serum creatinine (circles connected by black lines) and plasma albumin (triangles connected by blue lines) at different time points; Lower panel: A: Computed tomography scan shortly after the detection of hemorrhage showing perirenal hematoma (A2), without pleural effusion (A1); B: Perirenal hematoma and small amount of ascites (B2), with pleural effusion (B1, asterisk) 1 mo after the hemorrhage, the compressed kidney is also visible (B2, arrow); C: Perirenal fluid retention and ascites (C2), with pleural effusion (C1, asterisk) 5 mo after the hemorrhage. Alb: Albumin; CT: Computed tomography; Scr: Serum creatinine.

Figure 2

Schematic showing the flow of renal lymphatic fluid. Inflow from the capsular lymph plexus went through the renal parenchyma via subcapsular and peritrabecular lymphatic sinuses and pericapillary space and eventually made confluence at the efflux lymphatic vessels for out-draining.