Lymphangiography in Chyluria

Abstract

Chyluria, or the passage of chyle in the urine, has been observed for centuries. Hippocrates mentioned several instances and described the case of a woman who voided oily urine several days after childbirth (6). The discovery of the circulation of lymph in 1651 by Jean Pecquet led to several explanations of chyluria. Valentine Andrea Moellenbrogii in 1670 ascribed chylous urine to an abnormal junction of the lymphatic and urinary systems; in some cases, however, he confused pyuria with chyluria. One century later Morgagni differentiated between the two. In 1891 Wolff proposed that chyluria was the result of excretion of chyle from the blood into the urine (10). Most authors at present agree that a fistulous communication between the lymphatic system and the urinary system is responsible for the condition (7, 11, 13, 14). This abnormal communication was first demonstrated in 1920, when Hampton (4) described the appearance of pyelolymphatic reflux, and later was illustrated by Wood (13), in 1929, in a report of pyelolymphatic reflux in a patient with chyluria. This is an important factor, although not all patients with chyluria show pyelolymphatic reflux (14) and this phenomenon is sometimes observed in normal subjects. Lymphangiography, the radiographic demonstration of the lymphatics by intralymphatic injection of an opaque medium, has now demonstrated the abnormal lymphatic channels and the retrograde flow of contrast material from the para-aortic lymphatics into the kidney and calyces. These are the actual channels involved in the fistulous communication with the urinary tract. This visualization of the retrograde flow of an opaque medium to the renal lymphatics and calyces has been observed only in chyluric patients (11). A review of the literature revealed but one article (11), which appeared in the French literature, on lymphangiography in chyluric patients. Since this is of considerable importance and interest, the following cases are presented here. The lymphangiograms were obtained by the technic described by Kinmonth and modified by Wallace (12). Case Reports Case I: D.R., a 63-year-old Puerto Rican female, was seen for the first time in 1962, with chyluria. Her most recent visit to Puerto Rico was in 1952. On physical examination there was no evidence of edema or wasting. The laboratory data revealed normal serum proteins. The urine was milky and contained 10 mg. per cent albumin, 15 to 20 pus cells and 25 to 30 red blood cells per high-power field. A twenty-four-hour collection of urine revealed a lipid content of 350 mg. per 100 ml. Blood, urine, and skin tests were negative for filariasis. Cystoscopy revealed efflux of milky white urine on the left side and clear efflux of urine on the right side. The retrograde pyelogram is reproduced in Figure 1, A. The lymphangiogram is seen in Fig. 2. Following lymphangiography, the patient has had no further chyluria.