Filariasis and traumatic chyluria as displayed by lymphangiography.

INTRODUCTION Chyluria is the presence of chyle in the urine, giving it a milky appearance. Chyle is the milky fluid taken up by the lacteals from the food in the intestine after digestion. It consists of lymph and emulsified fat that passes into the thoracic duct and subclavian veins. When there is extravasation of chyle into the thorax, it is called chylothorax and in the abdomen, chylous ascites. Chyluria is most often caused by filarial parasites (Wuchereria bancrofti), aortoiliac grafting, and trauma. Bipedal lymphangiography of the foot/hand is the radiologic special procedure where Ethiodol contrast is injected into the dorsal lymphatics to visualize flow to and from lymph nodes. It is used as a diagnostic as well as therapeutic procedure. Fluoroscopic control allows extravasation and circumvention of the Ethiodol into the abnormal communication of lymphatics into the pelvis, kidney, and/or bladder. Surgical correction may consist of tying off the thoracic duct and/or embolization. If not corrected, the patient develops protein-losing enteropathy. Two patients with chyluria were selected for this presentation with filariasis and traumatic chyluria (football injury to the abdomen). The traumatic chyluria displayed considerable loss of weight and was not corrected at surgery. The lymphatic vascular system develops at the end of the fifth week. This is about 2 weeks later than the development of the cardiovascular system. The current view is that the earliest lymph vessels arise as capillary offshoots of the endothelium of veins. The development of the pulmonary lymphatics parallel veins and appear at the hilum in the 6th to 7th week, and by the end of the 10th week they are found in the lung. Therefore, by the end of the 18th to 20th week, they are well developed in the lung and the separate distinct pulmonary lobules. Historically, lymphatics were first recognized in 300 BC by Herophilus. They were rediscovered some 2000 years later by Aselli in 1622. Bartholin coined the term lymphatics in 1653, and Rudbeck in that same year described pulmonary lymphatics. Pulmonary lymphatic bicuspid valves were first discussed in 1675. In 1952, the first lymphangiogram was performed by Kinmot. This was first accomplished by identifying the lymphatics with blue dye for accurate placement. The senior author has performed this procedure for more than 40 years as a routine diagnostic procedure. The purpose of this presentation was to demonstrate how the procedure is used in teaching anatomy of the lymphatic system to anatomists, medical students, and other health professionals and to localize sites of lymphatic extravasation. The plain x-ray films, normal lymphatics, and lymph nodes (Figures 1 and 2) are displayed within the pelvis and abdomen, fistulous communication within the right kidney—filariasis (Figure 3) (Wuchereria bancrofti), and traumatic fistulous communications within the left kidney (Figure 4).