Vol. 117, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1977 by The Williams & Wilkins Co.
Single Case Reports NE,PHROGENIC PLEURAL EFFUSION EUGENE G, LAFORET
GEORGE D, KORNITZER
From the Department of Surgery, Boston University School of Medicine, Boston and the Thoracic Surgery and Urology Services, Newton- Wellesley Hospital, Newton, Massachusetts
Although the presence of a pleural effusion is almost always indicative of an intrathoracic problem reflection will yield a certain number of extrathoracic causes, such as hypoproteinemia, Meigs' syndrome, pancreatitis and subphrenic abscess. The kidney is a close neighbor of the diaphragm and pleural cavity, and a case of renal stone associated with a small ipsilateral pleural effusion, which regressed with resolution of the primary process, is reported. A 40-year-old man was hospitalized on October 20, 1975 because of the sudden onset of excruciating left lower quadrant abdominal pain, colicky in nature and radiating to the left testis. There had been no gross hematuria. Physical examination showed direct tenderness in the left lower quadrant of the abdomen but no rebound tenderness or guarding. There was tenderness to percussion in the left costovertebral angle. The remainder of the physical examination was within normal
lateral projection (fig, 1, B) showed obscuration of the posterior costophrenic angle. The next day fluoroscopy of the chest, with lateral decubitus and oblique roentgenograms, demonstrated the abnormality to be a pleural effusion (fig. 2). Thoracocentesis was not attempted, The symptoms improved gradually and the temperature did not exceed 37.4C orally during hospitalization. The patient was discharged from the hospital 4 days later. Chest x-rays on November 10 showed no evidence of pleural
FIG. 1. A, posteroanterior chest x-ray at time of hospitalization. B, concomitant lateral chest x-ray shows density in posterior costophrenic angle.
limits. Oral temperature was 37C. Laboratory data were unremarkable except for microscopic hematuria. An excretory urogram (IVP) showed markedly delayed function on the left side, with hydroureter and hydronephrosis being noted several hours after injection. The ureter was visualized from the pelvis to the bladder, at which point a small calcification could be seen consistent with a calcium stone. A posteroanterior chest x-ray (fig. 1, A) on the day after hospitalization was clear but a Accepted for publication July 2, 1976. 118
effusion (fig. 3). An IVP was unremarkable. There have been no recurrences of urologic symptoms or pleural effusion 5 months later.
If an effort is made to inculpate renal disease in the genesis of a pleural effusion one might validly ask why it is apparently so rare. In fact, the association actually may be uncommon but,
NEPHROGE:NIC F'LEUR,AL EFFLiS10N
m u~~'"·.v,.,. the effusion nay be so small and transient that it escapes easy detection. In our a standard posteroanterior chest x-ray was unremarkable, with the presence of pleural fluid being suggested only on the lateral view and requiring additional radiographic maneuvers for confirmation. In 1968 Corriere and associates reported 2 instances of pleural effusion associated with hydronephrosis in which they considered the relationship to be causal. 1 They attempted to duplicate the clinical situation in dogs by ureteral ligation, right lymphatic duct obstruction, thoracic duct obstruction and various combinations of the foregoing procedures. Although pleural effusion did not develop acutely in any of the animals they were able to demonstrate that fluid in an obstructed collecting system diffused into the perirenal tissue and peritoneal fluid. Also, previous studies have shown that peritoneal fluid has ready access to the pleural cavities. Furthermore, the only long-term survivor of their experiments did have pleural effusion 11 months after the ureter had been obstructed. Although present evidence is not sufficiently strong to encourage more than a putative relationship between obstructive renal disease and pleural effusion the clinical and experimental data do suggest that pleural effusion may sometimes complicate hydronephrosis, that it may be small and difficult to detect and that it may regress spontaneously with resolution of the renal problem.
J. J.: Hydronephrosis as a cause of pleural effusion. Radiology, 90: 79, 1968.
1. Corriere, J. N., Jr., Miller, W. T. and Murphy,
FIG. 2. Oblique x-ray demonstrates abnormal density on left side
FIG. 3. A, posteroanterior chest x-ray after resolution of urologic problem. B, concomitant lateral chest x-ray shows clear posterior costophrenic angle.