NYU Medical Grand Rounds Clinical Vignette Neelja Kumar, MD PGY 3 October 20, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

54 year old African American man presenting with left sided testicular pain for one week Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The pain began one week prior to presentation, associated with testicular swelling and tenderness The pain did not improve with over the counter medications so he presented to the emergency department History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: none Past Surgical History: none Social History: 20 pack-year smoking history, denies alcohol or drug use Worked as a college professor Family History: none Allergies: No Known Drug Allergies Medications: None U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: healthy appearing, in no distress Vital Signs: T: 98.3 BP: 226/121 HR: 78 RR: 14 O2 Sat: 99% on room air Left testicular tenderness to palpation Trace non pitting edema in lower extremities to knees bilaterally Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: Hemoglobin/Hematocrit: 11/31 Remainder of CBC was within normal limits Basic Metabolic panel: BUN/Creatinine: 36/2.3 Remainder of basic was within normal limits Hepatic panel: within normal limits Urine Analysis: coarse granular casts, 3+ protein, 5-10 red blood cells U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings Protein to creatinine ratio 1.7; equivalent to 1.7g per day Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus negative C3, C4 normal ANA negative Double Stranded DNA negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Electrocardiogram: normal sinus rhythm with left ventricular hypertrophy Testicular ultrasound: mildly complex bilateral hydroceles U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Orchitis Stage 3 Chronic kidney disease secondary to hypertensive nephrosclerosis Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 1: –The patient was started on ciprofloxacin for presumed orchitis –Nicardipine drip initiated for hypertensive emergency Hospital Day 3: - Kidney ultrasound performed demonstrated increased cortical echogenicity bilaterally Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 5: –Testicular pain resolved Hospital Day 7: - Given renal failure and findings on renal ultrasound, a renal biopsy was performed Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Renal Biopsy Duplication of elastic lamina in interlobular artery Hematoxylin and Eosin Stain: sclerosis with hyalinosis

Renal Biopsy Periodic acid-Schiff stain: segmental sclerosis and adhesion to Bowman’s capsule

Hypertensive nephrosclerosis with secondary Focal Segmental Glomerulosclerosis. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS