A Patient with Milky Urine: Nonparasitic Chyluria and Silver Nitrate Sclerotherapy

Abstract

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.

Chyluria Associated With Nephrotic-Range Proteinuria

“…They treated the patient with diethylcarbamazine initially; however, surgical closure was needed, as the patient did not respond to medical therapy [ 13 ]. Sivashankar et al reported a case of chyluria that was managed by endoscopic sclerotherapy [ 14 ].…”

The Case of a 15-Year-Old With Non-Parasitic Chyluria

“…Sudan III test may also be used. The most accurate method is the evaluation of triglyceride levels in urine [ 4 , 5 ]. In our case the levels of triglycerides were 2.7 mmol/L, we also found chylomicrons.…”

“…Using rigid cystoscopy to demonstrate chyle efflux from the ureteric orifice helps determine which side the chyluria originates from. It is also helpful in excluding other pathologies [ 4 ]. Fluoroscopy used to visualise the central lymphatic pathways may be performed with US-guided injection of oil-based contrast material.…”

“…Other more common side effects, including nausea, vomiting, flank pain, and haematuria, are usually transient. Not all patients respond well to sclerotherapy with 10%-40% of patients suffering a recurrence of chyluria [ 4 ]. In our case, sclerotherapy was unsuccessful.…”

“…Depending on the microfilaremic burden and in severe cases a febrile reaction may occur, therefore an antihistaminic agent is usually added to the therapy [ 14 ]. If all other treatment options fail to produce results, a pyelo-lymphatic disconnection procedure may be required [ 4 ].…”