CASE 10997 Published on 30.09.2013

A tropical tale of chyluria and complications due to sclerosants


Uroradiology & genital male imaging

Case Type

Clinical Cases


Anirudh V Nair, P V Ramachandran

Amrita institute of medical science,Amrita school of medicine,Radiology; Elamakkara 682026 Cochin, India;

42 years, male

Area of Interest Urinary Tract / Bladder ; No Imaging Technique
Clinical History
Patient was treated in an outside hospital with endoscopic silver nitrate instillation for complaints of chyluria. One day later, he started having acute left loin pain,tenderness and pallor. He was referred to our center for further management.
Imaging Findings
Plain CT abdomen: Enlarged left renal silhouette with branching calcific linear density within the calyceal system and parenchyma suggestive of argyrosis of the urinary tract (fig:1)

CECT abdomen: Heterogeneously enhancing, enlarged left renal parenchyma with fixity to left psoas muscle and a large pseudo-aneurysm at left renal pelvis. (fig:2-a, b).
Chyluria results due to fistulous communications between intrarenal lymphatic vessels and urinary collecting system.


Classification based on etiological factors are broadly divided into two groups, parasitic and non-parasitic causes (1):

1. Parasitic causes: Wuchereria bancrofti-90%, Taenia echinococcus, Taenia nana, Ankylostomiasis, Trichiniasis, Malarial parasites.

2. Non-parasitic causes: Congenital Lymphangioma of urinary tract, Megalymphatics & urethral/vesical fistulae, Stenosis of thoracic duct, Retroperitoneal lymphangiecatasia, Traumatic lymphangiourinary fistulae, Obstruction of thoracic duct/ lymphatics (tumor, granulomas, aortic aneurysm), Other causes (pregnancy, diabetes, abscess), Nephrotic syndrome


Non-surgical management:
-Dietary modification with fat restricted and high protien diet
-Diethyl cabamazine when filariasis is the cause for chyluria .

Curative management:
-Minimally invasive endoscopic sclerotherapy(2),
-Open surgery(4),
-laparoscopic surgery(5, 6)

Complications of sclerotherapy:

Common: Flank pain, nausea, vomiting are common and haematuria ocassionally seen with silver nitrate instilation.
Rare complications: Spillage of sclerosant at pelviureteric junction or ureter can cause chemical inflammation resulting in ureteric stricture, renal papillary necrosis, arterial hemorrhage, pseudoaneurysm, acute renal failure with argyrosis of urinary tract (7, 8, 9, 10, 12)

Take home message:

Complications of sclerotherapy (silver nitrate instillation) is more often due to improper use of sclerosant. Precautions to be taken so as to avoid complications include (11):

1) Avoid using higher concentration of silver nitrate (not more than 3 % of silver nitrate solution)
2) forceful instillation and injection of sclerosant more than the pelvic volume would lead to pyelovenous and pyelolymphatic reflux resulting in vascular and parenchymal damage.
3) Donot wash with normal saline. As normal saline would preciptate silver chloride, which is an opaque precipitate causes obstruction.
Differential Diagnosis List
Argyrosis of left upper renal tract with pseudoaneurysm.
Final Diagnosis
Argyrosis of left upper renal tract with pseudoaneurysm.
Case information
DOI: 10.1594/EURORAD/CASE.10997
ISSN: 1563-4086