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Magnetic resonance lymphangiography in recurrent chylous ascites and chyluria
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Magnetic resonance lymphangiography in recurrent chylous ascites and chyluria Li Wang1, Jiachang Chi2, Suqin Li1, Xiaolan Hua1, Hui Tang1 and Qing Lu1 1
Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; and 2Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China Correspondence: Qing Lu, Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 160 Pujian Rd, Shanghai 200127, China. E-mail: [email protected] Kidney International (2017) 91, 1522; http://dx.doi.org/10.1016/j.kint.2016.12.026 Elsevier Inc. All rights reserved.
Copyright ª 2017, International Society of Nephrology. Published by
Figure 1 | Three-dimensional maximum intensity projection reconstructed magnetic resonance lymphangiography shows tortuous and dilated lymphatic vessels twisting the left spermatic cord (thick arrow) and extending into the left retroperitoneum (thin arrows) after a left-sided inguinal nodal gadopentetate injection. Multiple enlarged inguinal lymph nodes in the left side were clearly delineated (arrowheads). Chylous effusion could be visualized in the pelvic cavity (star). The right spermatic cord shows a normal linear structure with low-signal intensity (hollow arrow). Bar ¼ 50 mm.
Figure 2 | Three-dimensional maximum intensity projection reconstructed magnetic resonance lymphangiography in an anteroposterior view to show tortuous hyperplasia of the left lumbar trunk (longer arrows) extending to the left renal hilum and communicating with the renal pelvis (arrow). Dispersion of contrast media into retroperitoneal and perirenal space (arrowheads) demonstrates abrupt discontinuation of the lymphatic vessels leading to chylous leakage. Cistern chyli (short arrow) and bilateral renal pelvis (hollow arrows) were clearly revealed. Bar ¼ 50 mm.
33-year-old man was referred with recurrent chylous ascites and chyluria. He had been diagnosed with hydrocele of the tunica vaginalis for 10 years and had undergone surgery at another hospital 6 weeks prior. Chylous ascites and chyluria ensued immediately after surgery. Review of systems was negative for vomiting, diarrhea, or fever, and the physical examination was unrevealing except for the presence of ascites. Testing of ascites fluid test revealed red blood cell count 45,025 106/l, white blood cell count 3452 106/l, glucose 5.82 g/l, protein 9.41 g/l, and triglyceride 2.2 g/l. Urine analysis confirmed the presence of chyluria. Bacterial urine analysis and circulating Wuchereria bancrofti assay were negative. Computed tomography showed abdominopelvic effusions and multiple lymphangiomata in the spleen. Chylous ascites and chyluria may be due to surgical ligation of the lymphatic channels to communicate, which leads to lymphatic hypertension and rupture or transudation of the lymphatic system. Magnetic resonance lymphangiography with the intranodal injection of gadolinium-based contrast material into the bilateral inguinal lymph nodes was conducted. Tortuous and
dilated lymphatic vessels were seen along the left spermatic cord (Figure 1) and left lumbar trunk extending to the left renal hilum (Figure 2). Communication of these lymphatic vessels with the renal pelvis was clearly depicted (Figure 2). Chylous leakage sites were detected at the inferior pole of the left kidney and peritoneal. The patient underwent laparoscopic renal pedicle lymphatic disconnection and retroperitoneal lymphatic ligation with subsequent resolution of his chylous ascites and chyluria. The patient did not show recurrence of chylous ascites and chyluria at the 9-month follow-up. Contrast-enhanced magnetic resonance lymphangiography may be a useful tool in the workup of chylous ascites and chyluria. It may allow for the identification of abnormal lymphatic vessels related to chyluria and chylous leakage, allowing for the possibility of corrective surgery.
A
1522
ACKNOWLEDGMENTS
This research was supported by the National Natural Science Foundation of China (81271638, 81371622) and the Shanghai Pujiang Program (15PJ1405200). We thank Dr. Xiaye Lu and Dr. Li Liu, Department of Emergency, Shanghai Renji Hospital, for assistance with the examination. Kidney International (2017) 91, 1522
www.kidney-international.org
Magnetic resonance lymphangiography in recurrent chylous ascites and chyluria Li Wang1, Jiachang Chi2, Suqin Li1, Xiaolan Hua1, Hui Tang1 and Qing Lu1 1
Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; and 2Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China Correspondence: Qing Lu, Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 160 Pujian Rd, Shanghai 200127, China. E-mail: [email protected] Kidney International (2017) 91, 1522; http://dx.doi.org/10.1016/j.kint.2016.12.026 Elsevier Inc. All rights reserved.
Copyright ª 2017, International Society of Nephrology. Published by
Figure 1 | Three-dimensional maximum intensity projection reconstructed magnetic resonance lymphangiography shows tortuous and dilated lymphatic vessels twisting the left spermatic cord (thick arrow) and extending into the left retroperitoneum (thin arrows) after a left-sided inguinal nodal gadopentetate injection. Multiple enlarged inguinal lymph nodes in the left side were clearly delineated (arrowheads). Chylous effusion could be visualized in the pelvic cavity (star). The right spermatic cord shows a normal linear structure with low-signal intensity (hollow arrow). Bar ¼ 50 mm.
Figure 2 | Three-dimensional maximum intensity projection reconstructed magnetic resonance lymphangiography in an anteroposterior view to show tortuous hyperplasia of the left lumbar trunk (longer arrows) extending to the left renal hilum and communicating with the renal pelvis (arrow). Dispersion of contrast media into retroperitoneal and perirenal space (arrowheads) demonstrates abrupt discontinuation of the lymphatic vessels leading to chylous leakage. Cistern chyli (short arrow) and bilateral renal pelvis (hollow arrows) were clearly revealed. Bar ¼ 50 mm.
33-year-old man was referred with recurrent chylous ascites and chyluria. He had been diagnosed with hydrocele of the tunica vaginalis for 10 years and had undergone surgery at another hospital 6 weeks prior. Chylous ascites and chyluria ensued immediately after surgery. Review of systems was negative for vomiting, diarrhea, or fever, and the physical examination was unrevealing except for the presence of ascites. Testing of ascites fluid test revealed red blood cell count 45,025 106/l, white blood cell count 3452 106/l, glucose 5.82 g/l, protein 9.41 g/l, and triglyceride 2.2 g/l. Urine analysis confirmed the presence of chyluria. Bacterial urine analysis and circulating Wuchereria bancrofti assay were negative. Computed tomography showed abdominopelvic effusions and multiple lymphangiomata in the spleen. Chylous ascites and chyluria may be due to surgical ligation of the lymphatic channels to communicate, which leads to lymphatic hypertension and rupture or transudation of the lymphatic system. Magnetic resonance lymphangiography with the intranodal injection of gadolinium-based contrast material into the bilateral inguinal lymph nodes was conducted. Tortuous and
dilated lymphatic vessels were seen along the left spermatic cord (Figure 1) and left lumbar trunk extending to the left renal hilum (Figure 2). Communication of these lymphatic vessels with the renal pelvis was clearly depicted (Figure 2). Chylous leakage sites were detected at the inferior pole of the left kidney and peritoneal. The patient underwent laparoscopic renal pedicle lymphatic disconnection and retroperitoneal lymphatic ligation with subsequent resolution of his chylous ascites and chyluria. The patient did not show recurrence of chylous ascites and chyluria at the 9-month follow-up. Contrast-enhanced magnetic resonance lymphangiography may be a useful tool in the workup of chylous ascites and chyluria. It may allow for the identification of abnormal lymphatic vessels related to chyluria and chylous leakage, allowing for the possibility of corrective surgery.
A
1522
ACKNOWLEDGMENTS
This research was supported by the National Natural Science Foundation of China (81271638, 81371622) and the Shanghai Pujiang Program (15PJ1405200). We thank Dr. Xiaye Lu and Dr. Li Liu, Department of Emergency, Shanghai Renji Hospital, for assistance with the examination. Kidney International (2017) 91, 1522