1. X-ray Conference Presented by F1 林立原 Commented by Dr. 王俐人 2011/07/13

2. CASE 1: 20698462 CASE 2: 21500213

3. CASE 1: 20698462

4. General Data Age: 44-year-old Gender: female Ethnic: Taiwanese Marital status: Married Occupation: 工人 Admission date: 2011/06/30

5. Chief Complaint Right flank pain for 1 day

6. Present Illness This 44-year-old female has unremarkable medical history before. She presents to the Urology OPD because of right flank pain for 1 day, along with fever episodes. At the beginning, she visited St. Paul hospital, where kidney echogram disclosed a right renal mass measuring 7cm in diameter. She denies gross hematuria, urinary frequency, urgency, dysuria, body weight loss, or abdominal pain.

7. Past History Severe left hand crushing injury by the machinery at work in Feb, 2004, post complete amputation flap.

8. Personal History No known allergy to food or drugs Denies smoking, alcoholism, or betel nuts chewing.

9. Physical Examination BT 38.1 ℃ PR: 115/min, RR: 18/min, BP: 115/91mmHg Consciousness: alert and oriented HEENT: pink conjunctiva, anicteric sclera Chest: smooth respiration, bilateral clear breathing sounds. Heart: regular heart beats, no murmurs. Abdomen: soft and flat, normoactive bowel sounds Knocking pain: negative Extremity: freely movable, no pitting edema.

10. Laboratory Findings Hemogramunit6/28 WBC/uL12600 RBCmillion/uL4.42 Hemoglobing/dL11.6 Hematocrit%35.7 MCVfL80.8 MCHpg/cell26.2 MCHCg/dL32.5 RDW%12.7 Platelets/uL300k Segment%81.0 Lymphocyte%11.3 Monocyte%7.3 Eosinophil%0.2 Basophil%0.2

11. BiochemistryUnit6/28 BUNmg/dL7.8 Crmg/dL0.68 ALK-pU/L55 ALTU/L23 NaMeq/L136 KMeq/L3.6 Laboratory Findings

12. Urinalysis2010/6/28 ColorYellow TurbidityCloudy Sp. Gravity1.014 pH6.5 Leukocyte1 + Nitrite+ ProteinNegative GlucoseNegative KetoneNegative Urobilinogen0.1 BilirubinNegative Blood1+ RBC11 WBC120 Epi.30

13. KUB

14. 2011/06/29 Kidney Echo

15. Left Kidney Length: 10.5 cm Right Kidney Length: 12.0 cm There is mild pelvocalyceal dilatation over right central sinus area. There is a mixed echoic lesion (8.1*6.0 cm) without acoustic shadow protruding from the middle portion of right kidney.

16. 2011/6/29 Abdominal CT

17. 2010/6/29 Abdominal CT

19. Right renal mass (6.8 x 5.2 cm) at upper pole presented with multiloculated cysts and internal septatations. The renal tumor extended into the right renal pelvis region, causing dilatation of right renal calyx. The cystic component is fluid density. No obvious locoregional lymphadenopathies. Multiloculated cystic nephroma was considered. DDx: cystic RCC, renal abscess.

20. Urine cytology Negative for malignancy

21. Diagnosis 1. Right renal cystic mass, rule out renal cell carcinoma 2. Right acute pyelonephritis

22. Discussion What is the nature of the renal mass?

24. Solid renal masses Renal cell carcinoma Oncocytoma: central scar, homogenous Angiomyolipoma: fat tissue Metanephric adenoma: rare disease

25. Solid renal masses Imaging studies cannot reliably distinguish benign solid lesions from renal cell carcinoma (RCC). Surgical resection is generally indicated.

26. CASE 2: 21500213

27. General Data Age: 51-year-old Gender: male Ethnic: Hakka Marital status: married Occupation: truck driver

28. Chief Complaint Sudden onset of fever with chills for 1 day

29. Present Illness This 51-year-old male has unremarkable medical diseases. He presented to the ED with sudden onset of fever with chills for 1 day, associated symptoms including poor appetite and abdomen fullness for one week, micturition burning sensation and left side flank pain for 2 days.

30. Present illness He denies difficult urination, urinary frequency, urgency or turbid urine. He visited Far Eastern Memorial hospital initially, urinary tract infection with bacteremia(B/C: GNB) was impressed; by his family’s request, he was transferred to CGMH.

31. Past History Left hydrocele known for one year, without any treatment Meningitis history 20 years ago

32. Personal History No known allergy Smoking: 2 pack per day for more than 30 years Alcohol consumption: 高梁酒 0.5 bottle/day, beer 3 bottle/day more than 30 years Betel nut chewing: occasional

33. Physical Examination BT 38.1 ℃ PR: 107/min, RR: 20/min, BP: 157/77mmHg General appearance: fair Consciousness: alert and oriented HEENT: pink conjunctiva, anicteric sclera Chest: symmetrical chest expansion, bilateral clear breathing sounds. Heart: regular heart beats Abdomen: soft, normoactive bowel sounds CV angle knocking pain over left side Extremity: freely movable, no pitting edema Left hydrocele about 10*5 cm, no tenderness

34. Laboratory Findings Hemogramunit7/03 WBC/uL9700 RBCmillion/uL3.32 Hemoglobing/dL9.1 Hematocrit%25.9 MCVfL78.0 MCHpg/cell27.4 MCHCg/dL35.1 RDW%13.4 Platelets/uL160k Segment%87.0 Lymphocyte%6.0 Monocyte%4.0 Band%1.0 Atypical Lym%1.0

35. BiochemistryUnit7/037/06 BUNmg/dL20.2 Crmg/dL1.641.54 ALK-pU/L55 ALTU/L26 NaMeq/L128126 KMeq/L2.43.9 CRPMg/L134 Laboratory Findings

36. Urinalysis2010/7/3 ColorYellow TurbidityClear Sp. Gravity1.007 pH6.5 Leukocyte2 + NitriteNegative Protein1+ GlucoseNegative KetoneNegative Urobilinogen1.0 BilirubinNegative Blood3+ RBC11 WBC66 Epi.0 Blood and urine culture: E. coli

37. 2011/07/04 Kidney echo

38. 2011/07/04 Kidney Echo Left kidney length: 11.4cm Right kidney length: 11.8 cm The cortical echogenicity is increased with increased thickness in right kidney. The right pelvocalyceal system is mild dilated. There is acoustic shadow like pattern in the upper-middle area of left kidney suspecting emphysematous change.

39. 2011/07/04 Abdominal CT

43. 2011/07/04 Chest CT (C+/-) Present feacture of emphysematous pyelonephritis on Lt, and nephritis on Rt Feacture of urinary bladder with air bubbles. Enlarged LNs along aorta probably reaction. Hydrocele, L’t groin. Splenomegaly Impressions: Emphysematous pyelonephritis on Lt, and acute nephritis on Rt

44. 2011/07/06 Surgical intervention Drainage of perirenal abscess OP Finding: two PCN was inserted into the reproperitoneal space to drain the emphyselomatous pyelonephritis No active bleeding

45. Diagnosis Left emphysematous pyelonephritis E. coli bacteremia, due to pyelonephritis Newly diagnosed diabetes mellitus Hyponatremia and hypokalemia

46. Discussion Brief review of emphysematous pyelonephritis

47. Emphysematous pyelonephritis Mean age: 60 y/o (37-83 y/o) Male : Female= 1: 6 Major risks: diabetes mellitus, urinary tract obstruction The main causes of urinary tract obstruction were papillary necrosis rather than ureteral calculi Usually caused by Escherichia coli(69%) or Klebsiella pneumoniae(29%) Arch Intern Med 2000; 160:797.

48. Emphysematous pyelonephritis Diagnostic instruments: plain films, ultrasound, CT scan. CT scan is the most sensitive Treatment: nephrectomy or open drainage along with systemic antibiotics

49. Emphysematous pyelonephritis ClassificationInvolved areaPrognosis 1Gas in collecting system only1/16(6.25%) dead, PCN is effective 2Renal parenchymal 3AExtension to perinephric space6/28(21.4%) dead 3BExtension to pararenal space 4Bil. pyelonephritis2/4(50%) dead Arch Intern Med 2000; 160:797.

50. Emphysematous pyelonephritis Risk factors of mortality : 1. Bilateral involvement 2. On imaging, renal parenchymal necrosis with either no fluid content or a streaky/mottled gas pattern 3. Conservative therapy without PCD 4. Thrombocytopenia J Urol 2007; 178:880.

51. THE END