1. X ray conference 2012.06.13 報告者： fellow 1 陳筱惠

2. Case 01

3. Patient Profile Name: 紀 O 雀 Sex: female Age: 72-year-old Chart number: 21520569 Date of admission: 2012/05/01

4. Chief Complaint Sudden onset of right flank pain for 1 day

5. Present Illness Underlying heart disease Sudden onset of right flank pain for 1 day Associated S/S: fever and nausea, no hematuria, frequency, or other urinary symptoms

6. Past History Unkown heart diseases before, other significant systemic diseases: denied Current medicine: nil

7. Personal History Allergy: no known allergy Alcohol: denied; betel-nut: denied; cigarette: denied Over-the-counter medication or chinese herb: nil

8. Family History No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

9. Physical Examination Vital signs: blood pressure: 144/89mmHg; temperature: 37.2‘C; pulse rate: 141/min; respiratory rate: 20/min General appearance: acute ill looking Eye: conjunctiva: pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein engorgement Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive Back: right flank knocking pain Extremities: no lower limb pitting edema Skin: intact, no rash

10. Laboratory data – 04/30 WBC16.4x1000/ul Hgb9.8 g/dl Hct29.5 % MCV88.9 fl PLT189 x1000/uL Segment87 % Sugar249 mg/dl BUN24.5 mg/dl Creatinine1.53 mg/dl Lipase29 IU/L Alk-p61 IU/L GPT20 IU/L Na137 mEq/L K4.8 mEq/L CRP74.17 mg/L

11. Urinalysis – 04/30 04/30 urine culture: - ColorYellow TurbidityClear SP. Gravity1.087 PH5.5 Leukocyte- Nitrite- Protein2+ GlucoseTrace Ketone- Urobilinogen0.1 Bilirulin- BloodTrace RBC3/uL WBC0/uL Epithelial cell1/uL

12. Abdominal CT – 04/30

13. Heterogenous content mass (83x85x50-mm) seemingly derived from the R’t renal cortex. Presence of contrast extravsation seen in the delay phase suggestive of low-pressure bleeding. Hemorrhage infiltration in the subcapsular, peri and para-renal space. No discernible enhancing soft tissue inside the hematoma No evidenced of blood clots in the collecting system or urinary bladder

14. Angiography – 05/01 A small pseudoaneurysm in the branch of right superior renal artery without contrast extravasation  Transcatheter angiographic embolization

15. Hospitalization course 5/17 urologist’s consultation: right angiomyolipoma (AML) with bleeding ▫Conservative treatment ▫Elective exploratory laparotomy for kidney hematoma/nephrectomy 5/24 kidney echo 6/8 uro opd: follow up CT

16. Discussion – spontaneous renal bleeding Wünderlich's syndrome: causes, diagnosis and radiological management Clin Radiol. 2002 Sep; 57 (9): 840-5

17. Etiologies: ▫61.5% tumor (31.5% malignant, 29.7% benign) ▫17% vascular disease ▫2.4% infection ▫6.7% idiopathic Etiology of spontaneous perirenal hemorrhage: A meta-analysis. J Urol 2002;167:1593-6

18. Managements: ▫Radical nephrectomy  For high incidence of small renal tumors when no apparent etiology and normal contralateral kidney with careful pathologic examination Spontaneous subcapsular renal hematoma: Diagnosis and management. J Urol 1988; 139: 246-50  Nonfatty lesions other than hematoma Rational approach to evaluation and management of spontaneous perirenal hemorrhage. Surg Gynecol Obstet 1990; 170; 121-5 ▫Operative exploration:  Not necessary because of the diagnostic accuracy of CT Spontaneous subcapsular and perirenal hematomas. Radiology 1989; 172: 601-2 ▫Follow- up CT at 3 month intervals until hematoma resolves and a definite diagnosis is possible

19. Case 02

20. Patient Profile Name: 詹 O 燕 Sex: female Age: 46-year-old Chart number: 21521255 Date of admission: 2012/05/12

21. Chief Complaint Right flank pain for days

22. Present Illness Underlying diseases: hypertension Right flank pain for days, with radiation to back Associated S/S: mild fever, no dysuria or hematuria LMD: treated as right acute pyelonephritis ▫Left renal mass was noticed accidentally.

23. Past History Underlying diseases: hypertension Other significant systemic diseases: denied Current medicine: antibiotics for APN

24. Personal History Allergy: no known allergy Alcohol: denied; betel-nut: denied; cigarette: denied Over-the-counter medication or chinese herb: nil

25. Family History No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

26. Physical Examination Vital signs: blood pressure: 125/78mmHg; temperature: 37.8‘C; pulse rate: 75/min; respiratory rate: 18/min General appearance: acute ill looking Eye: conjunctiva: not pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein engorgement Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs Abdomen: soft, flat, no abdominal tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: norm-oactive Back: mild right flank knocking pain Extremities: no lower limb pitting edema Skin: intact, no rash

27. Laboratory data – 05/11 WBC9.4x1000/ul Hgb12.9 g/dl Hct36.6 % MCV93.6 fl PLT371x1000/uL Segment65 % Meta-Myelocyte3% BUN14.9 mg/dl Creatinine1.01 mg/dl GPT32 IU/L NA138 mEq/L K3.5 mEq/L Sugar123 mg/dl

28. Urinalysis – 05/11 05/11 urine culture: E.coli ColorYellow TurbidityClear SP. Gravity1.014 PH6.5 LeukocyteTrace Nitrite- Protein1+ Glucose- Ketone- Urobilinogen0.1 Bilirulin- Blood3+ bacteria+ RBC111/uL WBC38/uL Epithelial cell13/uL

29. Abdominal CT – 05/09

30. Hospitalization course 5/12 urine cytology: negative for malignancy Urologist’s consultation note: left renal mass, suspect hemorrhagic cyst, rule out renal cell carcinoma  Suggest surgical intervention

31. Case 03

32. Patient Profile Name: 蔡 O 梅 Sex: female Age: 56-year-old Chart number: 3693317 Date of admission: 2012/05/14

33. Chief Complaint Progressive left flank pain for 1 week

34. Present Illness Status post L’t ESWL in 2012/03, then double J drainage during 2012/03-2012/04 for left side renal stone with obstruction and UTI Recurrent left flank pain for 1 week Associated S/S: fever/chills and dysuria, no hematuria

35. Past History Status post L’t ESWL in 2012/03, then double J drainage during 2012/03-2012/04 for left side renal stone with obstruction and UTI Hypertension and diabetes mellitus under medication control, other significant systemic diseases: denied Current medicine: anti-hypertensive medication and oral hypoglycemia agent from LMD

36. Personal History Allergy: no known allergy Alcohol: denied; betel-nut: denied; cigarette: denied Over-the-counter medication or chinese herb: nil

37. Family History No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

38. Physical Examination Vital signs: blood pressure: 137/71mmHg; temperature: 37.3‘C; pulse rate: 103/min; respiratory rate: 18/min General appearance: acute ill looking Eye: conjunctiva: mild pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein engorgement Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive Back: left flank knocking pain Extremities: no lower limb pitting edema Skin: intact, no rash

39. Laboratory lab – 05/12 WBC10.5x1000/ul Hgb11.6 g/dl Hct34.3 % MCV82.5 fl PLT192x1000/uL Segment73.5 % Sugar173 mg/dl BUN8.9 mg/dl Creatinine0.77 mg/dl GPT22 IU/L NA135 mEq/L K3.2 mEq/L CRP32.39 mg/L

40. Urinalysis – 05/12 05/12 urine culture: - ColorOrange TurbidityCloudy SP. Gravity1.011 PH6.0 Leukocyte1+ Nitrite+ Protein- Glucose- KetoneTrace Urobilinogen1.0 Bilirulin- Blood- RBC0/uL WBC3/uL Epithelial cell1/uL

41. Kidney echo – 05/12

42. Left kidney: 10.3 cm, right kidney: 11.4 cm There is a heterogenous hypoechoic lesion (7.6 x 3.7 cm) in the middle portion of the left kidney with extravasation to the outer surface of the left renal capsule.  Suspect hematoma with central necrosis or secondary infection and local extravasation to the perirenal region No obvious evidence of renal stone, mass or cyst

43. Abdominal CT – 05/14

44. Subcapsular cystic mass (50x37-mm) that in thick-wall and focal penetrating into the regional posterior pararenal space related to local infiltrative mass  Sugges L’t renal abscess with local rupture associated regional infiltration, DDx: cystic tumor

45. Hospitalization course 5/15 CT guided pigtail drainage of left renal abscess, pus culture: E.coli

46. Thanks for your listening

47. Kidney echo – 05/24

48. Left kidney: 10.7 cm, right kidney: 11.6 cm There is one hetergenous mass lesion in the low pole of right kidney (6.8 cm x 7.0 cm) The right kidney is surround by some hypoechoic substance suspecting hematoma.