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In some patients the entire lymphangiographic study may be completed in less than 1 hour (instead of the normal time of 4-6 hours) because of the dilated collateral vessels. The cisterna chyli is also often dilated and the thoracic duct is frequently visualized (Fig. 26.18). Contrast medium can flow into the renal lymphatics, outlining the calyces, infundibula, and renal pelvis (Figs. 26.19, 26.20): flow into calyces may also occur. In some patients, dilated lymphatics may be seen around the urinary bladder. In India, in the infected group noted earlier, the lymphangiographic findings seem to confirm the suggestion that there may be a stage of abnormal flow preceding the development of clinical elephantiasis (Fig. 26.19).

Fig. 26.18. After a pedal lymphangiogram, the AP radiograph of the thoracic region of a South Indian patient with chyluria shows a dilated thoracic duct and a few additional varices, seen near its junction with the left innominate vein. (Courtesy of Dr. A. Chandrahasan Johnson).


Fig. 26.19A-C. A patient with bancroftian filariasis and chyluria from Southern India. A This pedal lymphangiogram shows contrast rapidly entering dilated lymph varices in the right groin. Para-aortic and paracaval collaterals communicate with perirenal varices bilaterally. The lymph nodes have been bypassed, and are often palpable clinically. B Another Indian patient with chyluria: a radiograph taken 30 min postinjection of contrast in the right foot. Perirenal lymphatics are well seen, as well as lymph varices in the renal and right inguinal regions. There is reflux of the contrast into the left inguinal region, through wide varices and also a dilated cisterna chyli. (The thoracic duct was normal.) C Another Indian patient with chyluria with findings similar to those in B. There is retrograde flow of lymph along the course of the left testicular artery, which passed into a left hydrocele (not shown). (Courtesy of Dr. A. Chandrahasan Johnson)


Fig. 26.20A-C. Pedal lymphangiograms in Indian patients with chyluria. A A left pedal injection shows absence of lymph node opacification and numerous inguinal, iliac, and para-aortic lymph varices. The renal calices are opacified and there is contralateral filling of the right renal lymph varices. Some lymphangiogram contrast has passed down the ureter to opacity the urinary bladder. B A single radiograph from an intravenous urogram shows dilated para-aortic and lymph varices around both renal hila. There is asymmetrical, bilateral hydronephrosis, which is not uncommon, due to chylous or blood clots. The excretion from the left kidney is delayed and chyluria was more severe on that side. C A conventional tomogram of the left kidney shows the pericalyceal lymphatics which form rings around the clubbed calyces in the upper pole of the kidney. (Courtesy of Dr. A. Chandrahasan Johnson).

Differential Diagnosis

The commonest causes of elephantiasis are filariasis, tuberculosis, pyogenic infections, and malignant disease, especially Kaposi's sarcoma. Lymphangiography can sometimes provide differentiating features when the clinical diagnosis is uncertain: for example, clinically unsuspected Kaposi's sarcoma nodules may be seen on lymphangiograms (see Chapter 42 on Kaposi Sarcoma). Mycetoma (Madura foot, see Chapter 6 on Mycosis) must also be considered: in fungal infections, multiple sinuses and bone infection are characteristic. Chronic lymphedema from Milroy's disease and idiopathic elephantiasis (podoconiosis) must be considered in the differential diagnosis, with the latter usually having a well-defined geographic origin (see discussion of elephantiasis later in this chapter).

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