X-ray Conference

X-ray ConferencePresented by F1 Commented by Dr.2011/11/09Case 1: 21082252Case 2: 21505562Case 1: 21082252

General DataAge: 44-year-oldGender: maleEthnic: TaiwaneseMarital status: MarriedOccupation:Admission date: 2011/09/05Chief ComplaintDizziness for 1 dayPresent IllnessThis 44-year-old male has hypertension, and chronic kidney disease for 1 year, which was noticed by a health exam.He presents with dizziness for one day, along with nausea and vomiting.No spinning sensation, tinnitus, blurred vision, palpitation, chest tightness/pain, shortness of breath, fever, URI symptomsPresent IllnessAt ER, high BP was noticed.(234/135 mmHg) Under the impression of hypertension crisis, he was admitted.Past HistoryChronic hepatitis BHypertension known for one year, under Bisoprolol 5mg QD, Minoxidil 5mg QD, Lercanidipine 10mg QD, Doxazosin 4mg QD, Indapamide 1.5mg QDHyperlipidemiaPersonal HistoryNo known allergy to food or drugsSmoking: 1 pack per day for 20 yearsDenies alcoholism, or betel nuts chewing.Physical ExaminationT 35.5 P: 79/min, R: 16/min, BP: 234/135mmHgHeight: 164cm, weight: 52.3kg, BMI:19.4Consciousness: alert and orientedHEENT: pink conjunctiva, no thyroid goiterChest: smooth respiration, bilateral clear breathing sounds.Heart: regular heart beats, no murmurs.Abdomen: soft, flat, normal bowel soundsExtremity: freely movable, no pitting edema.Laboratory FindingsHemogramunit9/4WBC/uL9700RBCmillion/uL4.01Hemoglobing/dL11.0Hematocrit%34.2MCVfL85.3MCHpg/cell27.4MCHCg/dL32.2RDW%16.2Platelets/uL87kSegment%75.1Lymphocyte%15.0Monocyte%7.3Eosinophil%2.6Basophil%0.3BiochemistryUnit9/49/05BUNmg/dL40.3Crmg/dL4.18Camg/dL8.8Pmg/dL4.0NaMeq/L137KMeq/L3.9MgmEq/L1.6CK-MBng/mL0.8Troponin Ing/mL0.040.061Laboratory FindingsLaboratory FindingsUrinalysis09/09ColorYellowTurbidityClearSp. Gravity1.007pH6.5LeukocyteNegativeNitriteNegativeProtein1+(30)GlucoseNegativeKetoneNegativeUrobilinogen0.1BilirubinNegativeBlood3+RBC>500WBC2Epi.30CXR

14ImpressionsSuspect secondary hypertension, poor control with hypertensive emergencyChronic kidney disease, stage 4, eGFR: 16.7ml/min/1.73m2

Hospitalization course9/08 Kidney echoCr: 4.18 (9/04)Cr: 11.0 (9/08)Cr: 16.8 (9/13)9/19 CTA of Abdomen9/15Start HD9/26 operationUnit9/7Free T4ng/dL1.33TSHuIU/mL1.661Cortisolug/dL13.4Reninpg/ml182Aldosteronepg/ml401CatecholamineNormalVMANormal2011/09/08 Kidney Echo

The both kidneys are normal in size with mildly irregular contour. The cortical echogenicity is increased with adequate thickness. The pelvicalyceal systems are not dilated. 172011/09/08 Kidney Echo

2011/09/08 Kidney EchoLeft Kidney Length: 9.0 cmRight Kidney Length: 9.5 cmThe left kidney is borderline small in size and the right kidney is normal in size, both with mildly irregular contour. The cortical echogenicity is increased with adequate thickness. The pelvocalyceal systems are not dilated. No obvious evidence of renal stone, mass or cyst is noted. No adrenal gland mass is noted.2010/09/19 Abdominal CT

2010/09/19 Abdominal CT

2010/09/19 Abdominal CT

2010/09/19 Abdominal CTMultiple outpouch of abdominal aorta at the level of SMA root to the aortic bifurcation. Some infiltrative soft tissue in the peri-aortic region (Se5 Im29, 34~39). Mycotic aortic aneurysms is suspected. Mural thrombus in some of the aneurysm sac is seen.No definite supra-renal mass is seen. Large amount of ascites in the peritoneal cavity, cause unknown.Mild splenomegaly. Gastric varices, indicating portal hypertension.Mild cardiomegaly. Bil. pleural effusion, nature unknown. Minimal atelectasis of BLLs.Impression: 1. Multiple abdominal aortic aneurysm with peri-aortic soft tissue, R/O mycotic aneurysm.2. No evidence of pheochromocytoma in the bil. adrenal gland or retroperitoneum.3. Ascites and pleural effusion, nature unknown.Echocardiography(09/20)EF: 67%; Dilated LA, Dilated LV; Thick LV Walls.Adequate LV and RV Contractility. However, Mild LV posterior segment Hypokinesia was noted, Nature?Mild MR, Mild TRMild to Moderate Pulmonary Hypertension!!Modeate amount of pericardial effusion=200 ml. no fibrin deposition, no RA or RV Compression.Left pleural effusion was also noted. nature?No thrombus, no vegetation, no mitral stenosis.09/26 OP and Angiography1. The aortography revealed califlower aneurymal dilation of aorta with multiple separation involving SMA, bilateral renal arteries, and downward to aortic bifurcation. Pseudoaneurysms or mycotic aneurysm was considered.2. After successful canulation of guided wire, chimney for the SMA with viabahn 8mm/10 cm followed by implantation of left side manibody Gore Excluder PXT 261418 plus iliac PXC 121000, right side iliac PXC 141400 plus PXL 161207 landed on bilateral CIAs.Impression: Abdominal aortic pseudoaneurysms or mycotic aneurysm S/P successful EVAR.DiagnosisMultiple abdominal aortic aneurysmAcute kidney injury, RIFLE-F, in uremic stage, on maintenance hemodialysis since 09/15Secondary hypertension, due to abdominal aortic aneurysm with involvement of bilateral renal arteryDiscussionCase 2: 21505562General DataAge: 73-year-oldGender: maleEthnic: TaiwaneseMarital status: marriedOccupation: farmerChief ComplaintRight adrenal mass noticed in Present IllnessThis 73 year-old male has hypertension and arrythmia with OPD follow-up in hospital. He was sent to hospital because of sudden onset of conscious loss on 08/31, when he was reading. Hypokalemia and UTI were impressed, but he did not regain conscious. Present illnessThus he was transferred to , where right adrenal mass with hyperaldosteronism was noticed (renin:0.34ng/ml/hr, aldosterone 532.40pg/ml); and he was transferred to CGMH for surgical intervention.

Past HistoryHypertensionSick sinus syndrome with high grade AV block post permanent pacemaker implantation on 2011.9.10Paroxysmal atrial fibrillationBenign prostatic hypertrophy post operation

Personal HistoryNo known allergy to foods or drugsSmoking: 1 pack per day for more than 20 yearsAlcoholism: deniesBetel nut chewing: deniesPhysical ExaminationBT 36 PR: 81/min, RR: 20/min, BP:133/92mmHgHeight: 170cm, weight: 73kg, BMI:25.2Consciousness: alert and orientedHEENT: pink conjunctiva, anicteric scleraChest: symmetrical expansion, bilateral clear breathing sounds.Heart: regular heart beatsAbdomen: soft , normoactive bowel soundsExtremity: freely movable, no pitting edema

Laboratory FindingsHemogramunit9/19WBC/uL9800RBCmillion/uL4.21Hemoglobing/dL13.4Hematocrit%39.6MCVfL94.1MCHpg/cell31.8MCHCg/dL33.8RDW%13.9Platelets/uL133kSegment%83.0Lymphocyte%10.0Monocyte%6.0Eosinophil%0Meta-myelo%1.0BiochemistryUnit9/199/22BUNmg/dL2919.3Crmg/dL1.010.74Sugarmg/dL156ALTU/L20NaMeq/L145142KMeq/L4.52.2MgMeq/L1.7Albuming/dL3.28Laboratory Findings39Laboratory FindingsUrinalysis9/22ColorYellowTurbidityCloudySp. Gravity1.012pH8.5Leukocyte3 +Nitrite+Protein2+GlucoseNegativeKetoneNegativeUrobilinogen1.0BilirubinNegativeBlood3+RBC67WBC104Epi.0Unit9/22ReninPg/mL19.8AldosteronePg/mL446ACTHPg/mL68)Catechol-EUg/dayNDCatechol-DoUg/day143.1CXR

KUB

2011/09/26 Kidney echo

2011/09/26 Kidney EchoLeft kidney length: 10.9cmRight kidney length: 11.3 cmThe both kidneys are normal in size with normal outline. The cortical echogenicity is increased with adequate thickness.There is an iso to hypo-echoic heterogenous lesion (5.2x3.6cm) in the right supra-renal region.2011/09/13 Abdominal CT

Operation and Pathology10/04: Right adrenectomy with retroperitoneal tumor dissectionPathology: Highly suggestive of cortical carcinoma

DiagnosisRight adrenal cortical carcinoma, complicated with hypokalemia and secondary hypertension

DiscussionAdrenal massThe maximum diameter of the adrenal mass is predictive of malignancy. Most adrenal adenomas are < 4 cm in diameter. The lipid-rich nature of cortical adenomas is helpful in distinguishing this benign tumor from carcinomaCT, MRI, PETAdrenocortical carcinomasInhomogeneity, irregular borders, calcifications, invasion of surrounding structures or lymph node enlargement; 4 cm at diagnosisAdrenocortical carcinomasEpidemiology: one to two per million population per yearPeak: < 5y/o or between 40 to 50 y/o60% of ACCs are secretary; Cushing's syndrome alone (45%), overproduction of both glucocorticoids and androgens(25%), virilization alone(10%)The most common sites of distant spread for ACC are the liver, lungs, lymph nodes, and boneHormone evaluationEuropean Network for the Study of Adrenal Tumors (ENSAT) recommends: fasting glucose, serum K, cortisol, ACTH, 24-hour urinary free cortisol, fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasoneat bedtime, adrenal androgens (DHEAS, androstenedione, testosterone, 17-OH progesterone), and serum estradiol in men and postmenopausal womenAdrenocortical carcinomasStage5-yr survivalI82Confined to the adrenal gland without local invasion or distant metastases; greatest tumor dimension 5 cm (5.6%)II58Same as stage I but with tumor size >5 cm (42.3%)III55Tumor of any size with at least one of the following factors: tumor infiltration in surrounding tissues (T3), tumor invasion into tumor thrombus in the vena cava or renal vein (T4), positive lymph nodes (N1) but no distant metastases (16.1%)IV18Distant metastases (36.1%)The end