Diagnostic dilemma: Nephrology
A String of Beads

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Presentation

It is often said that timing is everything; certainly this is true in many medical situations. A 28-year-old woman presented with a 36-hour history of left loin pain and vomiting but no urinary symptoms, rigors, arthralgias, or rashes. Her past medical history included 2 pregnancies complicated by hypertension. She was febrile and hypertensive (154/80 mm Hg) with left-flank tenderness. No abdominal masses, bruits, or signs of peritonitis were detected. She was taking no medications.

Assessment

A urinalysis showed white blood cells (5-10/mm3) but no protein or casts. The serum white blood cell count (19 × 103/mm3) and C-reactive protein level (248 mg/L) were elevated. Hemoglobin, platelets, urea, electrolytes, a coagulation profile, and liver function tests were normal, although alanine aminotransferase was slightly elevated (121 U/L) at 72 hours. An electrocardiogram was normal, as were chest and abdominal radiographs. Abdominal and pelvic ultrasonography identified a small amount of

Diagnosis

Computed tomography led to a diagnosis of left renal infarction secondary to thrombi within the left renal artery. Subsequent angiographic findings indicated underlying fibromuscular dysplasia—implicating dissection as a possible mechanism of thrombosis.

The incidence of acute renal infarction has been estimated to be about 0.007%, but an earlier post-mortem study indicated that the incidence might be as high as 1.4%, suggesting under-diagnosis.1, 2 Without prompt treatment, ischemia provokes

Management

The patient began treatment with warfarin. She remained hypertensive despite medications. On renogram, the left kidney was found to contribute only 11% of the overall clearance. Nephrectomy was identified as a possible treatment for refractory hypertension.

In summary, renal infarction is under-diagnosed and a high index of suspicion is required for early recognition. Use of plain computed tomography with contrast enhancement in patients with acute flank pain might detect renal infarction. An

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Charles M. Wiener, MD, Section Editor

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