Chyluria has become a rare clinical presentation in Sri Lanka, which may have a direct correlation with the low prevalence of lymphatic filariasis following the use of diethylcarbamazine and albendazole mass drug administration (MDA) for five rounds between 2002 and 2006. Here we report a 50-year-old male who presented with milky urine and progressive weight loss, diagnosed as having nonparasitic chyluria. The patient was initially managed with a trail of diethylcarbamazine (DEC) 6 mg/kg/day for 21 days and a low-fat diet with an unsatisfactory response. Subsequent management with endoscopic instillation of 0.5% silver nitrate brought in him a quick response, which was maintained for a year. Endoscopic sclerotherapy is considered a safer, effective and a minimally invasive treatment option for symptomatic patients.
The presence of intestinal lymph (chyle) in the urine is known as chyluria. From the etiological perspective, chyluria is classified into two types: parasitic and nonparasitic (
A 51-year-old male was admitted with a complaint of milky urine and significant weight loss (10 kg) for over four months. On further assessment, neither lower urinary tract symptoms nor a contact history of tuberculosis was observed. The patient was cachectic with a body mass index of 20.2 kg/m2.
Macroscopically, urine appeared milky in colours (Figure
The color of urine samples prior and after the endoscopic sclerotheraphy, (a) prior to sclerotheraphy, (b) post surgery day 5, (c) one month after surgery.
Cystoscopy view showing the chyluria.
Left side retrograde pyelogram is showing the main lympho-urinary fistula at renal pelvis close to pelvic ureteric junction (marked by arrow).
Initially, he was managed with a low-fat diet and a trial of diethylcarbamazine 6 mg/kg/day for 21 days with an inadequate response. Persistent symptoms, despite initial management, encouraged us to change over to instillation therapy. 10 ml of 0.5% silver nitrate was instilled endoscopically to the left ureter via a 6 Fr ureteric catheter, and the procedure was repeated for another three cycles at 30 min intervals. Subsequently, bladder irrigation was continued for 12 hours, and cefuroxime was administered intravenously for three days. He had an uneventful recovery with complete clearance of urine over five days (Figure
Chyle is a milky fluid, rich in lymph and chylomicrons. Normally lymph flows through the intestinal lacteals to the cisterna chyle and the thoracic duct, which drain into the left subclavian vein. Although the pathogenesis of chyluria is not well described, two theories have been postulated: obstructive and regurgitative mechanisms for leakage of lymph into the urine (
Chyluria is confirmed by simple bedside chloroform or ether test, which extracts fat globules and forms an organic layer leaving the remaining urine clear. Sudan III test is also can be used to confirm fat globules in the urine. However, assessment of triglyceride levels in urine is by far the most accurate test to confirm chyluria when it is more than 15 mg/dl (
Ascertaining the etiology, side, and the site of chyluria is an important part of the management. Usually, ultrasound scan (KUB) and computed tomogram imaging of upper tracts would fail to provide the necessary information decisive to the management of chyluria. However, it may reveal an uncommon, incidental primary cause helpful in the management of nonparasitic chyluria. Magnetic resonance imaging might show clusters of dilated lymphatic channels (
Symptomatic patients with severe chyluria and malnutrition need intervention rather than a conservative approach (
Sabinis (1992) pointed out 1% silver nitrate sclerotherapy as a safer and minimally invasive treatment option with a success rate of 82.25% (
Sclerosant therapy has its drawbacks about side effects, out of which nausea, vomiting, flank pain, and haematuria are by far the commonest but transient (
10-40% of patients may develop recurrence following sclerotherapy requiring the procedure to be repeated (
Failure of endoscopic instillation sclerotherapy requires a pyelo-lymphatic disconnection procedure as a final therapeutic option.
Chyluria is a rare clinical presentation demanding a high index of clinical suspicion, and symptomatic patients need surgical intervention to relieve symptoms. In this clinical scenario, the assumption of chyluria of nonparasitic origin is valid reasoning in accordance with the detection of the low prevalence of lymphatic filariasis in Sri Lanka and the announcement of the eradication of lymphatic filariasis based on WHO criteria (
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