Renal infarction: an uncommon mimic presenting with flank pain

Bilateral renal infarction following atrial fibrillation and thromboembolism and presenting as acute abdominal pain: a case report

INTRODUCTION

Renal infarct is rare and often misdiagnosed because the symptoms are misleading. The mechanisms are various, mainly thrombotic and embolic.

CASE PRESENTATION

In this review, we report the case of a 61-year-old Tunisian woman presented to the emergency unit with a 4-hour history of abdominal pain diffused at both flanks, ultrasounds was performed to remove a surgical emergency, showed a peri-renal fluid collection with heterogeneous parenchyma.We followed by a CT scan, which confirmed the diagnosis of renal infarct. The patient was treated by heparin at a curative dose, and the outcome was favorable.

CONCLUSION

Diagnosis is difficult and should be considered in patients with inexplicable flank or abdominal pain and with risk factors to this disease. Our purpose is to raise clinician's awareness for this condition so that they will be more likely to diagnose it. This will facilitate prompt diagnosis and treatment.A review of the literature was performed and the case is discussed in the context of the current knowledge of this condition.

Sentinel central retinal artery occlusion: a forme fruste of idiopathic renal infarction

Central retinal artery occlusion is one of the most challenging practices and is not an infrequent presentation at the emergency department. We describe a 46-year-old man presenting with abrupt onset of amaurosis fugax secondary to sentinel central retinal artery occlusion followed by acute idiopathic renal infarction. This patient highlights that the preceding visual events could portend a devastating thromboembolic insult in the clinical setting. Early recognition with prompt treatment may preserve organ function, avoid unnecessary management, and prevent debilitating complication.

Pancreatic tail cancer with sole manifestation of left flank pain: a very rare presentation

Pancreatic cancer is sometimes called a "silent disease" because it often causes no symptoms in the early stage. The symptoms can be quite vague and various depending on the location of cancer in the pancreas. The anatomic site distribution is 78% in the head of the pancreas, 11% in the body, and 11% in the tail. Pancreatic cancer is rarely detected in the early stage, and it is very uncommon to diagnose pancreatic tail cancer during an emergency department visit. The manifestation of pancreatic tail cancer as left flank pain is very rare and has seldom been identified in the literature. We present a case of pancreatic tail cancer with the sole manifestation of dull left flank pain. Having negative findings on an ultrasound study initially, this female patient was misdiagnosed as having possible acute gastritis, urolithiasis or muscle strain after she received gastroendoscopy and colonofiberscopy. Her symptoms persisted for several months and she visited our emergency department due to an acute exacerbation of a persistent dull pain in the left flank area. Radiographic evaluation with computed tomography was performed, and pancreatic tail tumor with multiple metastases was found unexpectedly. We review the literature and discuss this rare presentation of pancreatic tail cancer.

Acute renal infarction in a heavy smoker

Renal infarction is a rare cause of acute abdominal and flank pain. Whether it occurs due to thrombosis or embolism, the occlusion of the renal arteries always results in renal infarction. Cigarette smoking is a known risk factor for arterial thrombosis. Both vasoconstrictor and pro-thrombotic effects of smoking lead to arterial thrombosis. Herein, we report a case of acute renal infarction in a heavy smoker. The definite diagnosis was made by contrast-enhanced abdominal computerized tomography and renal arteriography.

ED presentations of acute renal infarction

OBJECTIVE

The objective of the study was to investigate initial clinical characteristics that can suggest an early diagnosis of patients with acute renal infarction presenting with flank and/or abdominal pain in the emergency department (ED).

METHODS

From January 1, 1996, through December 31, 2005, 20 adult patients with renal infarction diagnosed by contrast-enhanced computed tomography in the ED were enrolled. Medical records, including demographic data, risk factors for thromboembolism, initial clinical presentations, laboratory data, treatment programs and outcomes, were retrospectively reviewed and analyzed.

RESULTS

Mean patient age was 60.3 years (range, 21-80). The estimated incidence of renal infarction was 0.004% (20 of 481,540) among the ED census. The median time of onset of symptoms before the ED visit was 31 hours (range, 1-285). Eighteen patients (90%) had a history of more than 1 risk factor for thromboembolic events. In clinical presentations, all the patients had either abdominal or flank pain and tenderness. Nineteen patients (95%) had an elevated serum lactate dehydrogenase level with a mean +/- SD of 812.1 +/- 569.4 U/L. Sixteen patients (80%) presented with the triad--persisting flank or abdominal pain/tenderness, elevated serum lactate dehydrogenase level, and proteinuria. Among all 20 patients, 10 patients (50%) were diagnosed as having renal infarction at the initial ED visit. No specific clinical characteristics could be identified to distinguish those patients diagnosed early and those with delayed diagnosis. All 20 patients received medical treatment with coumadin, which was given in combination with heparin treatment in 11, peripheral intravenous and/or local intra-arterial thrombolytics with urokinase in 5, and mitral valve replacement in 1. No patient died. Although 4 patients had a mildly elevated serum creatinine level (>1.5 mg/dL) during hospitalization, none of them needs dialysis after more than 1 year of follow-up.

CONCLUSIONS

In this study, we delineated specifically clinical features for emergency physicians to raise their suspicion index for an early diagnosis of patients with renal infarction, a disease which is uncommon and is usually delayed or missed at initial ED presentation.

Acute renal infarction: a 10-year experience

The diagnosis of acute renal infarction (ARI) is often delayed or unrecognised because of its non-specific presentation and the rarity of the disease. We evaluated the clinical presentations, laboratory findings, underlying medical conditions and treatment of 18 Chinese patients with ARI who presented to the emergency department (ED) of a tertiary teaching hospital from 1995 to 2004. We identified 14 non-trauma and four trauma patients with ARI. The mean duration from the onset of symptoms to the diagnosis of ARI was 1.9 days. The prevalence of concurrent events was 39%. About 64.5% of non-trauma patients had histories of atrial fibrillation, structural heart diseases or previous embolic events. The laboratory characteristics were neither specific nor sensitive for the diagnosis of ARI. Conservative treatment, local intra-arterial thrombolytic and i.v. thrombolytic therapies were provided in nine, five and two patients respectively. Decreased effective renal plasma flow in affected kidneys was found in three of three patients. Serum creatinine (Cr) was normal or elevated not more than 25% of baseline in 16 cases. ARI may resemble many non-renal diseases; however, repeated evaluation and a high index of suspicion are required for early diagnosis. Concurrent injuries or thromboembolism in other foci should be noticed. Early contrast-enhanced computerized tomography scan should be considered for high-risk patients. Patients with ARI should be followed by functional studies rather than serum Cr level.

[Acute renal infarction. Report of 2 cases]

Diagnosis of acute renal infarction is often delayed or missed due to both the rarity of the disease and its unespecific clinical presentation. Definitive radiologic diagnosis often requires invasive procedures such as angiography. Computed tomography (CT) may be useful in diagnosing acute renal infarction and is considered the standard of reference for diagnosis of acute renal infarction, with the advantage of being non-invasive and potentially available 24 hours a day. We report two cases, in the first case we show a segmentary renal infarction; at the second one we report a case of complete renal infarction. Presentation, diagnosis and therapeutic aspects are discussed.