X-ray Conference

Presented by F1 林立原Commented by Dr.王俐人2011/07/13

CASE 1: 20698462CASE 2: 21500213

CASE 1: 20698462

General DataAge: 44-year-oldGender: femaleEthnic: TaiwaneseMarital status: MarriedOccupation: 工人Admission date: 2011/06/30

Chief ComplaintRight flank pain for 1 day

Present IllnessThis 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.

Past HistorySevere left hand crushing injury

by the machinery at work in Feb, 2004, post complete amputation flap.

Personal HistoryNo known allergy to food or

drugsDenies smoking, alcoholism, or

betel nuts chewing.

Physical ExaminationBT 38.1℃ PR: 115/min, RR: 18/min, BP:

115/91mmHgConsciousness: alert and orientedHEENT: pink conjunctiva, anicteric scleraChest: smooth respiration, bilateral clear

breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft and flat, normoactive bowel

soundsKnocking pain: negativeExtremity: freely movable, no pitting

edema.

Laboratory FindingsHemogram

unit 6/28

WBC /uL 12600RBC million/uL 4.42Hemoglobin

g/dL 11.6

Hematocrit % 35.7MCV fL 80.8MCH pg/cell 26.2MCHC g/dL 32.5RDW % 12.7Platelets /uL 300kSegment % 81.0Lymphocyte

% 11.3

Monocyte % 7.3Eosinophil % 0.2Basophil % 0.2

Biochemistry Unit 6/28BUN mg/dL 7.8Cr mg/dL 0.68ALK-p U/L 55ALT U/L 23Na Meq/L 136K Meq/L 3.6

Laboratory Findings

Laboratory FindingsUrinalysis 2010/6/

28Color YellowTurbidity CloudySp. Gravity 1.014pH 6.5Leukocyte 1 +Nitrite +Protein NegativeGlucose NegativeKetone NegativeUrobilinogen 0.1Bilirubin NegativeBlood 1+RBC 11WBC 120Epi. 30

KUB

2011/06/29 Kidney Echo

2011/06/29 Kidney EchoLeft Kidney Length: 10.5 cmRight Kidney Length: 12.0 cmThere 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.

2011/6/29 Abdominal CT

2010/6/29 Abdominal CT

2010/6/29 Abdominal CT

2010/6/29 Abdominal CTRight 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.

Urine cytologyNegative for malignancy

Diagnosis1. Right renal cystic mass, rule

out renal cell carcinoma2. Right acute pyelonephritis

DiscussionWhat is the nature of the renal

mass?

Solid renal massesRenal cell carcinomaOncocytoma: central scar,

homogenousAngiomyolipoma: fat tissueMetanephric adenoma: rare

disease

Solid renal massesImaging studies cannot reliably

distinguish benign solid lesions from renal cell carcinoma (RCC). Surgical resection is generally indicated.

CASE 2: 21500213

General DataAge: 51-year-oldGender: maleEthnic: HakkaMarital status: marriedOccupation: truck driver

Chief ComplaintSudden onset of fever with chills

for 1 day

Present IllnessThis 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.

Present illnessHe 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.

Past HistoryLeft hydrocele known for one year,

without any treatmentMeningitis history 20 years ago

Personal HistoryNo known allergySmoking: 2 pack per day for

more than 30 yearsAlcohol consumption:高梁酒 0.5

bottle/day, beer 3 bottle/day more than 30 years

Betel nut chewing: occasional

Physical ExaminationBT 38.1℃ PR: 107/min, RR: 20/min, BP:

157/77mmHgGeneral appearance: fairConsciousness: alert and orientedHEENT: pink conjunctiva, anicteric scleraChest: symmetrical chest expansion, bilateral clear

breathing sounds.Heart: regular heart beatsAbdomen: soft, normoactive bowel soundsCV angle knocking pain over left sideExtremity: freely movable, no pitting edemaLeft hydrocele about 10*5 cm, no tenderness

Laboratory FindingsHemogram

unit 7/03

WBC /uL 9700RBC million/uL 3.32Hemoglobin

g/dL 9.1

Hematocrit % 25.9MCV fL 78.0MCH pg/cell 27.4MCHC g/dL 35.1RDW % 13.4Platelets /uL 160kSegment % 87.0Lymphocyte

% 6.0

Monocyte % 4.0Band % 1.0Atypical Lym

% 1.0

Biochemistry Unit 7/03 7/06BUN mg/dL 20.2Cr mg/dL 1.64 1.54ALK-p U/L 55ALT U/L 26Na Meq/L 128 126K Meq/L 2.4 3.9CRP Mg/L 134

Laboratory Findings

Laboratory FindingsUrinalysis 2010/7/3

Color YellowTurbidity ClearSp. Gravity 1.007pH 6.5Leukocyte 2 +Nitrite NegativeProtein 1+Glucose NegativeKetone NegativeUrobilinogen 1.0Bilirubin NegativeBlood 3+RBC 11WBC 66Epi. 0

Blood and urine culture: E. coli

2011/07/04 Kidney echo

2011/07/04 Kidney EchoLeft kidney length: 11.4cmRight kidney length: 11.8 cmThe 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.

2011/07/04 Abdominal CT

2011/07/04 Chest CT (C+/-)Present feacture of emphysematous

pyelonephritis on Lt, and nephritis on RtFeacture of urinary bladder with air

bubbles.Enlarged LNs along aorta probably

reaction.Hydrocele, L’t groin.SplenomegalyImpressions: Emphysematous

pyelonephritis on Lt, and acute nephritis on Rt

2011/07/06 Surgical interventionDrainage of perirenal abscessOP Finding: two PCN was inserted

into the reproperitoneal space to drain the emphyselomatous pyelonephritis

No active bleeding

DiagnosisLeft emphysematous

pyelonephritisE. coli bacteremia, due to

pyelonephritisNewly diagnosed diabetes

mellitusHyponatremia and hypokalemia

DiscussionBrief review of emphysematous

pyelonephritis

Emphysematous pyelonephritisMean age: 60 y/o (37-83 y/o)Male : Female= 1: 6Major risks: diabetes mellitus, urinary

tract obstructionThe 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.

Emphysematous pyelonephritisDiagnostic instruments: plain

films, ultrasound, CT scan. CT scan is the most sensitive

Treatment: nephrectomy or open drainage along with systemic antibiotics

Emphysematous pyelonephritisClassification

Involved area Prognosis

1 Gas in collecting system only

1/16(6.25%) dead, PCN is effective

2 Renal parenchymal3A Extension to perinephric

space6/28(21.4%) dead

3B Extension to pararenal space

4 Bil. pyelonephritis 2/4(50%) dead

Arch Intern Med 2000; 160:797.

Emphysematous pyelonephritisRisk factors of mortality:1. Bilateral involvement2. On imaging, renal

parenchymal necrosis with either no fluid content or a streaky/mottled gas pattern

3. Conservative therapy without PCD

4. ThrombocytopeniaJ Urol 2007; 178:880.

THE END