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X ray conference 2012.02.01

報告者： fellow 1 陳筱惠. X ray conference 2012.02.01. Case 01. Patient Profile. Name: 陳 O 綢 Sex: female Age: 52-year-old Chart number: 21512475 Date of admission: 2012/01/07. Chief Complaint. Intermittent gross hematuria about half year. Present Illness.

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X ray conference 2012.02.01

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  1. 報告者：fellow 1 陳筱惠 X ray conference2012.02.01

  2. Case 01

  3. Patient Profile • Name: 陳O綢 • Sex: female • Age: 52-year-old • Chart number: 21512475 • Date of admission: 2012/01/07

  4. Chief Complaint • Intermittent gross hematuria about half year

  5. Present Illness • Underlying diseases: hypertension, diabetes mellitus, and chronic kidney disease (stage 5) • Intermittent gross hematuria for about half year • Associated S/S: right flank pain and urinary frequency • No fever, weight loss, abdominal pain, general weakness, poor appetite, nause/vomiting, or dysuria • LMD: treated as UTIinitially, then MRI there with liver and right renal tumor

  6. Past History • Hypertension, diabetes mellitus, and chronic kidney disease (stage 5) • Urolithiasis: denied • Other significant systemic diseases: denied • Current medicine: anti-HTN medication and OHA from LMD

  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: 181/87mmHg; temperature: 36.8‘C; pulse rate: 96/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: mild right flank knocking discomforts • Extremities: no lower limb pitting edema • Skin: intact, no rash

  10. Laboratory data – 01/04

  11. Urinalysis – 01/04 • 01/04 urine culture: mixed flora

  12. Abdominal MRI – 12/19 T1 T2

  13. T1 T2

  14. Kidney bladder echo – 01/05

  15. Left kidney Length: 9.4 cm • Right kidney Length: 8.8 cm • 1 mixed-echoic mass lesion in the low pole (3.7 cm ) • Irregular contour, increased cortical echogenicity with reduced thickness; no pelvocalyceal system dilatation; no obvious renal stone or cyst

  16. Hospitalization course • 1/9 urine cytology: SUGGESTIVE OF MALIGNANCY • 1/12 CT guided kidney biopsy: CARCINOMA • BOTH RCC AND TCC ARE POSSIBLE. • 1/13 echo guided liver biopsy: POORLY DIFFERENTIATED CARCINOMA, METASTATIC • THE CD10 NEGATIVITY FAVOR IT TO BE OF UROTHELIAL ORIGIN.

  17. Discussion

  18. Case 02

  19. Patient Profile • Name: 徐O妹 • Sex: female • Age: 71-year-old • Chart number:21511980 • Date of admission: 2011/12/29

  20. Chief Complaint • Bilateral flank pain for several months

  21. Present Illness • Underlying diseases: hypertension, urolithiasis history • Bilateral flank pain for several months • Associated S/S: fever, nausea/vomiting • No abdomial pain, dysuria, or hematuria • LMD: poor renal function (BUN: 80, crea: 9.8) and bilateral renal stone

  22. Past History • Underlying diseases: hypertension • Other significant systemic diseases: denied • L‘t renal stone s/p PCWL and R‘t ureteral stone with hydronephrosis s/p DJ • Current medicine: anti-HTN medication from LMD

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

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

  25. Physical Examination • Vital signs: blood pressure: 246/136mmHg; temperature: 36‘C; pulse rate: 88/min; respiratory rate: 17/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: bilateral flank knocking pain • Extremities: no lower limb pitting edema • Skin: intact, no rash

  26. Laboratory data – 12/28

  27. Urinalysis – 12/28 • 12/28 urine culture: E.coli

  28. Abdominal CT – 12/28

  29. A outpouching mass adjacent right posteior kidney with calcification and suspicious necrotic center, surrounding with few lymph nodes and stranding fat-plane, RCC should be considered first. • Left ureteral stone (0.9 cm in diameter) and left calyceal stones • Bilateral hydronephrosis and bilateral hydroureter with thin renal cortex, suggesting chronic renal impairment. R/O right UP or upper ureter obstruction

  30. Kidney echo – 01/02

  31. Left Kidney Length: 11.4 cm • Hyperechoic lesions with acoustic shadow • Right Kidney Length: 10.7 cm • 1 heterogenous mass-like lesion (9.0x5.9cm) with 2 central calficication spot, protruding from upper pole with extention to right suprarenal fossa • The both kidneys are normal in size and contour. The cortical echogenicity and thickness are normal. • No evidence of renal stone or cyst • Mild-to-moderate pelvocalyceal dilatation over the central sinus area of bilateral kidney, with proximal ureteral dilatation

  32. Hospitalization course • 2011/12/28 OP: bilateral DOUBLE-J URETERAL STENT INSERTION • 2012/01/05 CT guided kidney biopsy: RENAL CELL CARCINOMA

  33. Case 03

  34. Patient Profile • Name: 陳O慧 • Sex: female • Age: 27-year-old • Chart number:20990430 • Date of admission: 2012/01/29

  35. Chief Complaint • Diffuse abdomninal dull pain with fever for 1 week

  36. Present Illness • Ectopic pregnancy history post operation in 2006; Ketamine drug abuser?? • Diffuse abdomninal dull pain for 1 week • Associated S/S: fever, dyspnea, dysuria, decreased urine output, nausea sensation

  37. Past History • Ectopic pregnancy history post operation in 2006 • Significant systemic diseases, like hypertension, diabetes mellitus: denied • Current medicine: nil

  38. Personal History • Allergy: no known allergy • Alcohol: social drainking; betel-nut: denied; cigarette: 1ppd/day for 8 years • Over-the-counter medication or chinese herb: nil • Ketamine drug abuser??

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

  40. Physical Examination • Vital signs: blood pressure: 142/88mmHg; temperature: 35.4‘C; pulse rate: 112/min; respiratory rate: 25/min • General apperance: 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: bilateral flank knocking pain • Extremities: no lower limb pitting edema • Skin: intact, no rash

  41. Laboratory data – 01/28

  42. Urinalysis – 01/28 • 01/28 urine culture: E.coli

  43. Abdominal CT – 01/28

  44. Markedly atrophy of right kidney • Left perinephric fat strandings; enlarged left kidney with heterogeneous parenchymal enhancement; dilated left pelvocalyceal system with strong wall enhancement • Long segmental left ureteral wall thickening with strictures • LNs enlargement at left renal hilum and left para-aortic space • No intraperitoneal free fluid, no extraluminal free air. • Elongated gallbladder without cholecystitis; The liver, spleen, pancreas are unremarkable.

  45. Kidney echo – 01/30

  46. Left Kidney Length: 13.8 cm • Increased echogenicity with prominent and heterogenous papillae  suspect acute papillary necrosis • Right Kidney Length: 0 cm • No evidence of renal stone or mass

  47. Discussion • Kidney: • Heroin and cocaine  focal segmental glomerulosclerosis (FSGS) • The exact cause of this condition remains in dispute. • Immune-mediated?? • Heroin: interstitial nephritis with fibrosis, lymphocytic and plasma cell infiltrates • Cocaine: more renovascular disease and interstitial nephritis than controls The histopathology of drugs of abuse Histopathology 2011, 59, 579–593

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