a 40-year - old colombian man living in central colombia , bogota , was referred to local hospital for turbid white urine that had appeared 2 months earlier .
milky. the phenomenon was intermittent : the patient would pass discoloured urine during 4 or 5 days without complaints of fever , burning or urgency . thereafter , the urine was clear or pink .
this anxious man had sought medical attention in various facilities , and despite the fact that no urinary tract infection was found by urine cytology and cultures , he had been repeatedly treated by urinary antibiotics that did not produce any effect on his albinuria .
causes of turbid white urine at first visit to our nephrology unit , the patient kept describing his urine as  milky. we verified that his description was appropriate by collecting urine in various occasions .
in fact , analysing the urine revealed a massive proteinuria of 5 g / l , microhaematuria ( 1520 red cells per ml ) and leucocyturia ( 1015 leucocytes / ml ) .
. a closer examination of urinary cytology showed that the white cell population consisted of abundant lymphocytes .
further investigations revealed a normal renal function , with a creatinine clearance in the order of 105 ml / min .
proteinuria was profuse ( 6.7 g/24 h ) , but serum albumin concentration was normal ( 43
g / l ) , and so were his serum lipids ( total cholesterol : 4.9 mmol / l , triglycerides 1.9 mmol / l ) .
no oedema , no hypoalbuminaemia , no hyperlipidaemia and fasting coincided with a clearing of the urine so it could not be a nephrotic syndrome .
the rest of the laboratory work up was also non - contributive : leucocytes 5700/mm , ( neutrophils 64% , lymphocytes 23% ) , haemoglobin 16.5 g / dl , haematocrit 48.2% , platelets 285.000/mm .
a cystoscopy that found white urine in the bladder ( thus excluding malingering ) did not disclose tumoural or infectious lesions .
the patient observed that the hospital diet that he found meagre also coincided with a clearing of the urine .
this remark prompted us to ask the department of nutrition to give him fat meals . with a lipid - rich diet urine turned white and clotty . with a fat - free diet
it was found that milky urine was demulsified with chloroform and sudan dye made it turn red .
a new cystoscopy was made with previous administration of a fat - rich diet and disclosed a punctiform hole in the posterior wall of the bladder with a leak of white fluid ( figure 3 ) .
iodopovidone closed the fistula and the patient was discharged with instructions to avoid fat foods .
cystoscopic view of white urine flowing from a hole in the bladder wall ( arrow ) .
its differential diagnosis includes phosphates , calcium and urates that in excess give the urine a turbid , white or cloudy appearance , although the amounts of these minerals are rarely high enough to produce albinuria .
the urine ph plays a role in provoking a turbid discolouration of the urine : claude bernard in his doctoral thesis presented in paris in 1843 explained that rabbits , a species feeding on vegetal , excrete alkaline turbid urine that turns clear by adding acid to it .
when thinking of mineral crystal deposits , some clues are given by the urine ph : phosphaturia is related to alkaline urine   and sediment analysis shows identifiable crystals .
when chyluria is centrifuged , it remains white , which permits to differentiate it from mineral deposits .
other substances that can induce albinuria are pus in severe urinary tract infections , or caseous material in urinary tuberculosis ( tb ) .
once such causes have been ruled out , the diagnosis of chyluria is likely to be appropriate , but this has no reason to be in non - endemic regions of filariasis infection , which was the case in our patient who lives in central colombia .
chyluria implies an abnormal communication between lymphatics and the urinary tract , mediated by any obstruction of intestinal lymph drainage resulting in lymphatic vessel dilatation and rupture into the urinary tract .
this parasitic disease is frequent in geographic areas between latitudes 40 north and 30 south .
about 10% of the population in these countries suffer from filariasis , and one - tenth of the affected patients present with albinuria caused by urinary - lymphatic fistulae .
nonetheless , chyluria can be related to other rare non - parasitic diseases   such as fungal infections , congenital abnormalities of the lymphatic vessels , malignancy , trauma and pregnancy .
white urine emission alternates with macrohaematuria and is sometimes accompanied with renal colic produced by chyle clots .
proteinuria is explained by the high concentration of albumin and fibrinogen in chyle ( 3060 g / l ) , and leucocyturia consists of lymphocytes . a lipid - rich meal is rapidly followed by albinuria , whereas a fat - free diet allows the urine to turn clear .
firstly , it shows that chyluria may occur in any part of the world , and that european readers may come across a case of albinuria in a patient who never lived in an endemic parasitic region where w. bancrofti infection is common .
secondly , diagnosing chyluria may simply be achieved by dietary manoeuvres , alternating a lipid - rich diet followed by a fat - free diet .
however , albinuria and chyluria may be caused by congenital   or acquired aetiologies of lymphatic fistulae .
when fortune smiles , as it was in our case , the urologist may observe white urine running from a punctiform hole and treat albinuria by sclerotherapy or povidone injection into the fistula .
however , a fat - poor diet must be pursued : the fistula might reopen , and besides , a patient whose bmi is 30 can not but benefit from it .
 turbid white urine  albinuria is defined as a urine discoloration described as milky or cloudy . 
 one of the most frequent causes of turbid white urine is chyluria complicating filariasis ( table 1 ) . 
 the extant causes of albinuria are non parasitic and rare . amongst their aetiologies 
 stand excessive mineral sediment excretion such as calciuria and phosphaturia , massive pyuria and fungal infections , and rarely congenital malformations of the lymphatic vessels . 
 malingering is also possible , in patients adding milk to their urine . 
 we observed a case of albinuria in which the diagnostic work up led to diagnosing an exceptional cause of chyluria in a patient living in a region of colombia where filariasis is not endemic . 
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