Wunderlich Syndrome is a rare potentially life-threatening phenomenon that involves spontaneous non-traumatic retroperitoneal hemorrhage. At present, identifying the course of conservative management in these patients, especially in pregnancy, has not been clinically established. Presented here is a known case of Tuberous Sclerosis Complex with a Bilateral, 10cm Angiomyolipoma in a 31-year-old female, initially managed with active surveillance. At 27 weeks of pregnancy, she presented with a sudden onset of left flank pain with a hematocrit of 22%. Anemia was corrected with blood transfusions. A contrast-enhanced MRI of the abdomen showed a large subcapsular perirenal hematoma of the left kidney. Renal angioembolization of the bleeding segmental renal artery was done. The patient was conservatized until 37 weeks of pregnancy and underwent cesarean section delivery.

Four months after angioembolization, she had a recurrence of the left flank pain associated with gross hematuria and hypovolemic shock. The patient underwent emergency renal exploration of the left kidney via a transabdominal approach. Three liters of hemoperitoneum and a large expanding left retroperitoneal hematoma were noted intraoperatively. Early vascular control before nephrectomy of the left kidney was done. The postoperative course was unremarkable and the patient was discharged with improved condition.

This case displays a unique course in the management of a bleeding angiomyolipoma especially during pregnancy. Renal angioembolization can aid in achieving the age of viability in pregnancy. However, close monitoring for rebleeding should be kept in mind. A lower threshold for conservative management should be utilized when patients have a previous history of bleeding.

Human ; Female ; Adult: 25-44 Yrs Old ; Abdomen ; Anemia ; Angiomyolipoma ; Arteries ; Blood ; Blood Transfusion ; Cesarean Section ; Conservative Treatment ; Emergencies ; Female ; Flank Pain ; Hematocrit ; Hematoma ; Hematuria ; Hemoperitoneum ; Hemorrhage ; History ; Hypovolemia ; Insemination, Artificial, Heterologous ; Kidney ; Life ; Nephrectomy ; Pain ; Patients ; Pregnancy ; Recurrence ; Renal Artery ; Research Report ; Sclerosis ; Shock ; Syndrome ; Tuberous Sclerosis ; Watchful Waiting

Actinomycosis can mask malignant diseases. This paper reports a case of colonic diffuse large B-cell lymphoma (DLBCL), which was misdiagnosed as abdominal actinomycosis. A 76-year-old woman presented with right flank pain and weight loss. Abdominal CT and colonoscopy revealed a huge ascending colon mass. Despite the initial impression of a malignancy, a colonoscopic biopsy revealed no malignant cells, but sulfur granules and a filamentous organism suggesting actinomycosis. Intravenous penicillin G was administered under the impression of abdominal actinomycosis but her condition deteriorated rapidly. Follow up CT showed markedly increased colon mass and new multiple nodular lesions around the ascending colon. Sono-guided percutaneous biopsy of the nodular lesion was performed. The pathological result was DLBCL. The patient was scheduled to undergo chemotherapy but the patient expired due to cancer progression. The diagnosis of gastrointestinal infiltrating tumors is often difficult because a superficial biopsy usually does not provide a confirmative diagnosis. This case highlights the difficulty in making a correct diagnosis of lymphoma due to the concomitant actinomycosis. Malignant conditions must be considered in cases of actinomycosis with no response to antimicrobial therapy.
Actinomycosis ; Aged ; B-Lymphocytes ; Biopsy ; Colon ; Colon, Ascending ; Colonic Neoplasms ; Colonoscopy ; Diagnosis ; Drug Therapy ; Female ; Flank Pain ; Follow-Up Studies ; Humans ; Lymphoma ; Lymphoma, B-Cell ; Lymphoma, Large B-Cell, Diffuse ; Masks ; Penicillin G ; Sulfur ; Tomography, X-Ray Computed ; Weight Loss

Renal cortical necrosis (RCN) is patchy or diffuse ischemic destruction of the renal cortex caused by significantly reduced renal arterial perfusion. It is a rare cause of acute kidney injury (AKI) and is associated with high mortality. Here, we review the case of RCN in a 15-year-old boy who developed AKI. A 15-year-old boy was referred to our hospital from a local hospital due to a sharp decrease in his renal function. He presented with acute flank pain, nausea with vomiting, and oliguria for the past two days. He had taken a single dose of antihistamine for nasal congestion. At our hospital, his peak blood pressure was 148/83 mmHg and he had a high body mass index of 32.9 kg/m². The laboratory data showed a blood urea nitrogen (BUN) of 28.4 mg/dL, a creatinine of 4.26 mg/dL, and a glomerular filtration rate estimated from the serum cystatin C of 20.2 mL/min/1.73m². Proteinuria (spot urine protein to creatinine ratio 1.66) with pyuria was observed. Kidney sonography showed parenchymal swelling and increased renal echogenicity. Due to rapidly progressing nephritis, steroid pulse therapy (750 mg/IV) was done on the second day of his admission and the patient showed complete recovery with normal renal function. However, the kidney biopsy findings revealed renal cortical hemorrhagic necrosis. Multifocal, relatively well-circumscribed, hemorrhagic necrotic areas (about 25%) were detected in the tubulointerstitium. Although RCN is an unusual cause of AKI, especially in children, pediatricians should consider the possibility of RCN when evaluating patients with rapidly decreasing renal function.
Acute Kidney Injury ; Adolescent ; Biopsy ; Blood Pressure ; Blood Urea Nitrogen ; Body Mass Index ; Child ; Creatinine ; Cystatin C ; Estrogens, Conjugated (USP) ; Flank Pain ; Glomerular Filtration Rate ; Humans ; Kidney ; Kidney Cortex Necrosis ; Male ; Mortality ; Nausea ; Necrosis ; Nephritis ; Obesity ; Oliguria ; Perfusion ; Proteinuria ; Pyuria ; Vomiting

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.
Aorta ; Diagnosis ; Estrogens, Conjugated (USP) ; Flank Pain ; Hematuria ; Renal Veins ; Spine

Actinomycosis can mask malignant diseases. This paper reports a case of colonic diffuse large B-cell lymphoma (DLBCL), which was misdiagnosed as abdominal actinomycosis. A 76-year-old woman presented with right flank pain and weight loss. Abdominal CT and colonoscopy revealed a huge ascending colon mass. Despite the initial impression of a malignancy, a colonoscopic biopsy revealed no malignant cells, but sulfur granules and a filamentous organism suggesting actinomycosis. Intravenous penicillin G was administered under the impression of abdominal actinomycosis but her condition deteriorated rapidly. Follow up CT showed markedly increased colon mass and new multiple nodular lesions around the ascending colon. Sono-guided percutaneous biopsy of the nodular lesion was performed. The pathological result was DLBCL. The patient was scheduled to undergo chemotherapy but the patient expired due to cancer progression. The diagnosis of gastrointestinal infiltrating tumors is often difficult because a superficial biopsy usually does not provide a confirmative diagnosis. This case highlights the difficulty in making a correct diagnosis of lymphoma due to the concomitant actinomycosis. Malignant conditions must be considered in cases of actinomycosis with no response to antimicrobial therapy.
Actinomycosis ; Aged ; B-Lymphocytes ; Biopsy ; Colon ; Colon, Ascending ; Colonic Neoplasms ; Colonoscopy ; Diagnosis ; Drug Therapy ; Female ; Flank Pain ; Follow-Up Studies ; Humans ; Lymphoma ; Lymphoma, B-Cell ; Lymphoma, Large B-Cell, Diffuse ; Masks ; Penicillin G ; Sulfur ; Tomography, X-Ray Computed ; Weight Loss

PURPOSE: A case of frosted branch angiitis in Kikuchi-Fujimoto disease is reported. CASE SUMMARY: A 33-year-old male complained of a sudden decrease in visual acuity that developed in both eyes 5 days prior. He suffered from a headache, chills, myalgia, and flank pain 1 week before. The initial best-corrected visual acuity (BCVA) was 0.1 in the right eye and 0.2 in the left eye. On slit lamp examination, no inflammatory finding was observed in the anterior chamber and vitreous body of both eyes. On fundus examination, a diffuse vascular sheathing-like frosted branch was found in the retinal vessels, and retinal hemorrhage was observed. Fluorescein angiography showed staining and leakage of dye along the vascular sheathing. Serological findings were negative, showing no evidence of an autoimmune disease or viral infection. Neck ultrasonography revealed non-tender left cervical lymph node enlargement >1 cm in diameter. Ultrasound-guided fine needle aspiration cytology showed findings compatible with Kikuchi-Fujimoto disease, including necrotic changes and pronounced karyorrhexis, plus histiocyte and lymphocyte infiltration without neutrophils. We started systemic steroid therapy. One month after treatment, the BCVA of both eyes improved to 1.0. CONCLUSIONS: In patients with frosted branch angiitis, systemic disease such as Kikuchi-Fujimoto disease should be considered.
Adult ; Anterior Chamber ; Autoimmune Diseases ; Biopsy, Fine-Needle ; Chills ; Flank Pain ; Fluorescein Angiography ; Headache ; Histiocytes ; Histiocytic Necrotizing Lymphadenitis ; Humans ; Lymph Nodes ; Lymphocytes ; Male ; Myalgia ; Neck ; Neutrophils ; Retinal Hemorrhage ; Retinal Vessels ; Slit Lamp ; Ultrasonography ; Vasculitis ; Visual Acuity ; Vitreous Body

Urolithiasis is suspected by flank pain, costovertebral angle tenderness, and hematuria, and confirmed by computed tomography (CT). Treatment strategy and likelihood of spontaneous passage of a stone were determined by size and position of ureteral calculi and complication detected by CT. In general, the purpose of urinalysis for urolithiasis is to confirm the hematuria and pyuria. However, sometimes albumin is detected by urine dipstick test in urolithiasis. Therefore, I performed this study to investigate the clinical significance of urine dipstick positive for albuminuria in urolithiasis. This study was a retrospective review of medical records of 150 patients who visited the emergency department and diagnosed with urolithiasis by CT between March 2010 and February 2014. The patients were divided into a albuminuria group and non-albuminuria group. General chracteristics, clinical features, laboratory results, and CT findings were compared. The incidence of stones >5 mm in diameter, hydronephrosis (≥grade 2) and upper ureter stone were significantly higher in albuminuria group than non-albuminuria group. In multivariate logistic regression analysis, hydronephrosis (≥grade 2) and upper ureter stone were significantly associated with albuminuria. Upper ureter stone and hydronephrosis (≥grade 2) are also known as predictors for failure of spontaneous passage of ureter calculi. If further studies are done, urine dipstick positive for albumin in urolithiasis can be used as a predictor for failure of spontaneous passage of ureter calculi.
Albuminuria* ; Calculi ; Emergency Service, Hospital ; Flank Pain ; Hematuria ; Humans ; Hydronephrosis ; Incidence ; Logistic Models ; Medical Records ; Pyuria ; Retrospective Studies ; Ureter ; Ureteral Calculi ; Urinalysis ; Urolithiasis*

While carbapenems are the drug of choice to treat extended-spectrum-β-lactamase (ESBL)-producing strains, some alternative carbapenem-sparing regimens are suggested for antibiotic stewardship. We experienced a case of ciprofloxacin treatment failure for acute pyelonephritis caused by an apparently susceptible Escherichia coli. A 71-year-old woman presented the emergency department with fever for 7 days and bilateral flank pain for 2 days. The laboratory results and abdominopelvic computed tomography finding were compatible with acute pyelonephritis. During 3-day ciprofloxacin therapy, the patient remained febrile with persistent bacteremia. After the change in antibiotics to ertapenem, the patient’s clinical course started to improve. ESBL-producing E. coli isolates were identified in all three consecutive blood samples. Pulsed-field gel electrophoresis (PFGE) patterns, serotypes, and sequence types showed the three isolates were derived from the identical strain. The isolates produced CTX-M-14 type ESBL belonging to the ST69 clonal group. Despite in vitro susceptibility, the failure was attributed to a gyrA point mutation encoding Ser83Leu within quinolone resistance-determining regions. This case suggests that ciprofloxacin should be used cautiously in the treatment of serious infections caused by ciprofloxacin-susceptible, ESBL-producing E. coli, even in acute pyelonephritis because in-vitro susceptibility tests could fail to detect certain genetic mutations.
Aged ; Anti-Bacterial Agents ; Bacteremia ; Carbapenems ; Ciprofloxacin* ; Electrophoresis, Gel, Pulsed-Field ; Emergency Service, Hospital ; Escherichia coli* ; Escherichia* ; Female ; Fever ; Flank Pain ; Humans ; In Vitro Techniques ; Point Mutation ; Pyelonephritis* ; Serogroup ; Treatment Failure

OBJECTIVE: The STONE score was developed to gauge the ureter stone probability. On the other hand, it is unclear if the STONE score is also applicable to Koreans. This study evaluated whether the STONE score can identify patients with suspected nephrolithiasis for whom a computed tomography (CT) scan can be obtained in the emergency department, targeting Koreans. METHODS: Patients presenting to the emergency medicine (ED) with flank pain and a suspicion of a ureter stone between January 2016 and December 2016 were reviewed retrospectively. After calculating the STONE score, the enrolled patients were classified into the low, moderate, high score group. In each group, the prevalence of a ureter stone and other clinical diseases on a CT scan were investigated. RESULTS: Among the 156 patients included in the analysis, 124 (79.5%) had a ureter stone and an alternative diagnosis was made in 12 (7.7%). The prevalence of a ureter stone and alternative diseases in the high score group was 87.7% (71/81) and 4.9% (4/81), respectively. The proportion of patients with nephrolithiasis increased significantly (P < 0.001), but the proportion of patients with other clinical diseases did not decrease significantly across the score groups (P=0.196). The area under the receiver operating characteristic curve was 0.711 (95% confidence interval, 0.633–0.780; P=0.001) with a cut off score higher than 8 (sensitivity 82.3%, specificity 50.0%) for the STONE score. CONCLUSION: In this setting, the STONE score had a low specificity and could not accurately assess a ureter stone. More studies aimed at Koreans are warranted before a CT scan can be limited using the STONE score.
Diagnosis ; Emergency Medicine ; Emergency Service, Hospital ; Flank Pain ; Hand ; Humans ; Nephrolithiasis ; Prevalence ; Retrospective Studies* ; ROC Curve ; Sensitivity and Specificity ; Tomography, X-Ray Computed ; Ureter* ; Ureteral Calculi

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare, and has been reported previously in pregnant patients in association with collagen vascular disease, and in cases of high-energy trauma or intensive activity in athletes. There is no consensus yet on indications for medical or surgical therapeutic modality. Due to the rarity of spontaneous dissection of external iliac artery, its natural history has been poorly described. A healthy 50-year-old male with normotension was admitted with an acute onset of left flank pain. Left external iliac artery dissection was diagnosed by abdominal computed tomography.
Aorta ; Arteries ; Athletes ; Collagen ; Consensus ; Extremities ; Flank Pain ; Humans ; Iliac Artery ; Male ; Middle Aged ; Natural History ; Stents ; Vascular Diseases