Renal papillary necrosis with urinary tract obstruction: A case report

BACKGROUND

Renal papillary necrosis (RPN) is a rare disease. It is difficult to distinguish RPN with urinary tract obstruction from upper urinary tract occupying lesions. We reported a case of RPN and made a definite diagnosis largely based upon its endoscopic characteristics.

CASE SUMMARY

A 75-year-old woman presented with right flank pain, visible hematuria and a body temperature greater than 39 ℃. Laboratory investigations revealed leukocytosis with 12.7 × 10/L white blood cells and 93.6% neutrophils. Blood creatinine was 333 umol/L. Ultrasonography showed hydronephrosis of the right kidney and a right distal ureteric lesion. After urgent placement of right ureteral double J stent and treatment with antibiotics, the patient’s symptoms and the blood abnormalities improved rapidly. Computed tomography urography showed the presence of multiple occupying lesions in the right pelvis. The endoscopic ureteroscopy revealed that renal papillary necrosis and the subsequent migration of sloughed papillae into the upper ureter and calyces. The sloughed papillae appeared like “cottons”, which were whitish, soft, and irregularly-shaped without blood supply. In addition, the necrotic and sloughed renal papillae were removed by flexible ureteroscopy to prevent further obstruction. Pathological examination found that infarcted renal papillae were associated with inflammatory exudation. Three months after discharge, follow-up computed tomography urography showed no obvious lesions in the renal pelvis.

CONCLUSION

This case revealed the endoscopic features of RPN. In addition, flexible ureteroscopy proves to be vital in diagnosis and treatment of RPN.

[Sickle cell trait complications: A case series of 6 patients]

INTRODUCTION

Patients with sickle cell trait (SCT) are commonly considered as asymptomatic carriers. However, some clinical manifestations may occur.

METHODS

Here we present a retrospective descriptive study about SCT subjects with at least one complication diagnosed in a sickle cell disease referral center, in Paris, between 2008 and 2019. We also performed a literature review on the complications of SCT subjects.

RESULTS

Six patients (between 19 and 65 years old) were included. SCT was already known only for 4 of them at the time of the complication. Four patients presented with a splenic infarct after a stay in high altitude or a plane trip, one of them was associated with papillary necrosis; one patient had isolated papillary necrosis, and the last one had splenic sequestration. These complications happened for most of them after exposure to an unusual situation of hypoxia or deshydratation. Five out of 6 patients had a marked elevated C reactive protein.

CONCLUSION

SCT may cause acute ischemic complications in a context of prolonged hypoxia or dehydration. The most commonly reported are the splenic infarct and the renal papillary necrosis. A study of hemoglobin should be considered in these clinical situations in patients with compatible ethnic origin.

Renal papillary necrosis in patients with sickle cell disease: How to recognize this 'forgotten' diagnosis

INTRODUCTION

Renal papillary necrosis is not commonly seen in daily practice, but can have severe consequences when it is not diagnosed in time. It is known to be associated with sickle cell hemoglobinopathies; however a wide range of etiologies are possible, and it is therefore not the first diagnosis clinicians consider in patients with sickle cell disease who present with hematuria.

METHODS

A literature search was performed to summarize the current knowledge about renal papillary necrosis associated with sickle cell disease. These findings are illustrated with a case of a 9-year old girl with sickle cell disease who was referred with painless gross hematuria.

RESULTS

Typical radiologic signs for renal papillary necrosis are necrotic cavities that fill with contrast, small collections of contrast peripheral to the calyces in the papillary region (ball-on-tee sign), calcification of the papillary defect, filling defects, hydronephrosis, blunted papillary tip, clefts in the renal medulla filled with contrast, hyperattenuated medullary calcifications, non-enhanced lesions surrounded by rings of excreted contrast, and clubbed calyces.

DISCUSSION

This study focuses on the pathophysiology of renal papillary necrosis associated with sickle cell disease, the possible symptoms, as well as the diagnostic steps, with a special interest in particular presentation on old (retrograde pyelography) and new (computed tomography) gold standard in radiologic imaging, and the management for this pathology.

CONCLUSION

This study aims to remind clinicians of this "forgotten" diagnosis and what signs to look for in pediatric patients with sickle cell disease who present with hematuria. In pediatric cases radiation protection is important, therefore knowing what radiologic signs can be found on retrograde pyelography can lead to early identification of this pathology without having to proceed to computed tomography.