Recurrent Chyluria Revisited: Lymphangiographic Diagnosis of Pyelolymphatic Fistula With Insights on Endolymphatic Interventions

Chyluria, the passage of chyle-laden lymph into urine, is most frequently linked to filarial infection but may also occur in diverse nonparasitic settings. We describe a 43-year-old man with diabetes, hypertension, and rheumatic heart disease who was admitted with prolonged fever and dyspnea and found to have infective endocarditis. The patient developed persistent milky urine during hospitalization that was unresponsive to a high-protein, low-fat diet supplemented with medium-chain triglycerides. Filariasis serology was negative. Although his comorbidities are not primary etiologic factors for chyluria, the systemic inflammation and lymphatic congestion associated with endocarditis likely triggered central lymphatic obstruction, the reflux of chyle into the renal lymphatics, and chyluria. Diagnostic intranodal lymphangiography with Lipiodol delineated multiple left-sided pyelolymphatic fistulae. No additional embolic agent was administered; nonetheless, Lipiodol's inherent inflammatory and embolic effects led to the complete resolution of chyluria within 24 hours. This case underscores the value of thorough etio-pathological assessment in nonparasitic chyluria, highlights structural lymphatic abnormalities as pivotal contributors to disease persistence, and demonstrates the evolving dual diagnostic-therapeutic role of intranodal lymphangiography. We further review current imaging algorithms and minimally invasive endolymphatic interventions that can obviate surgical treatment in refractory chyluria.