Severe filarial chyluria Managed successfully with sclerotherapy: A case report from Sudan

Abstract

Introduction

Chyluria is characterized by the passage of milky urine resulting from abnormal lymphatic drainage into the urinary tract. In parasitic cases, it is commonly caused by Wuchereria bancrofti and has varying severities. Diagnosis relies on clinical, laboratory, and radiological assessments, with treatment options spanning dietary modifications to surgical interventions.

Case presentation

A 43-year-old male presented with chyluria for one year. He received medical treatment for filariasis without response. sclerotherapy with 5 % povidone Iodine was done successfully.

Conclusion

Severe cases of chyluria can be treated successfully with povidone Iodine 5 %.

Highlights

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Chyluria results from abnormal lymphatic drainage into the urinary tract.
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The patient, after failing medical treatments, underwent successful sclerotherapy without significant complications.
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Treatment: Sclerotherapy with povidone Iodine proved effective for moderate to severe chyluria.
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Conclusion: Sclerotherapy with povidone Iodine is a safe and effective treatment for severe cases of chyluria.

1 Introduction

Lymph flows from the intestinal lymphatics to the thoracic duct and subsequently enters the left subclavian vein. Chyluria, characterized by the passage of milky-appearing urine, typically arises from abnormal retrograde or collateral lymphatic flow from the intestinal lymphatics into the lymphatics of the kidney, ureter, and bladder (KUB) system. The condition occurs when lymphatic vessels rupture and drain into the urinary tract. Chyluria was first described by Hippocrates around 400 BCE. While most reported cases originate from South Asia, a smaller number have been documented in sub-Saharan regions. ^, Causes of chyluria may be parasitic or non-parasitic. The common cause of parasitic infestation is Wuchereria bancrofti in 95 % of cases.

The most common clinical presentation of chyluria is the passage of milky urine, observed in approximately 70 % of cases. The condition is classified based on severity into mild, moderate, and severe categories. ^,

Intermittent episodes of milky urine characterize mild cases. Moderate cases present with sporadic episodes of milky urine, with or without clot colic. Severe cases involve persistent milky urine accompanied by one or more additional features, such as urinary retention, haematochyluria, or systemic symptoms like weight loss.

Chyluria is suspected clinically and confirmed by laboratory and radiological investigations. Management depends on the severity of the disease and ranges from dietary modification to surgery. This case report was done following the SCARE guideline for case reports.

Case report: A forty-three-year-old Sudanese male from Sennar State southeast Sudan presented to the urology clinic with milky urine for one year mainly at night and early morning, associated with lower urinary tract symptoms. There is no history of hematuria, back pain, trauma, or previous surgeries. However, he did mention that he had lost a significant weight during this time. Clinical examination revealed, a male of 170 cm, weighing 50 kg. Hemodynamically stable, with an unremarkable systemic examination.

Urine was milky in color, with two crosses of protein, triglyceride was 180 mg/d. 24 hours urine for Albumin was normal, serum cholesterol was normal, serum Albumin was 3.0 mg/dl, (CBC), kidney function, and liver function tests were all normal. Ether was added to a test tube filled with the cloudy urine rendering the mixture clear suggesting chyluria, A peripheral blood smear confirmed the presence of filarial parasites ( Fig. 1 ). An abdominopelvic ultrasound and chest X-ray showed no abnormalities. Based on these findings, the patient underwent cystoscopy, and a milky white fluid was observed coming from the left ureteric opening during the procedure ( Fig. 2 ).

We started first with a modification of dietary food and, anti-filariasis Ivermectin tablets 200 μg/Kg body weight for six days, this dose was repeated after 3 months, and after six months, but there was no improvement in his main complaint (milky urine). The patient consented to a retrograde pyelogram where a left pyelo-lymphatic fistula was confirmed ( Fig. 3 ). As a result, sclerotherapy was initiated using povidone-iodine. A ureteral catheter was inserted, and a solution of 10 ml of 10 % povidone-iodine mixed with 10 ml of distilled water was prepared (this equals 20 ml of 5 % povidone Iodine). The solution was injected in a 10 ml syringe through the ureteral catheter, held for 5 minutes, and then released. This process was repeated until the full amount of the solution was administered. The treatment was administered three times daily for three consecutive days.