Case time! I've got a good one for PAs and students alike

[VictoriaO]

This one has all the teams at my tertiary academic center scratching their heads..I'm saving this case for PA students as I hope to get into precepting someday. PA students, feel free to chime in, this is a great review of renal disease.

 

CC: Hematuria x 2 weeks

 

HPI: Ms. X is a 57 yo female now presenting to her local ED who was in her usual state of health until 2 weeks ago when she noticed pink-tinged urine. She did not see any blood on tissue or in toilet. Since then her urine has progressively become more red. Initially she had no associated symptoms but then about a week later began to feel tired and achey. She saw her PCP 4 days ago because of fatigue, nausea, vomiting, and new headache, had a U/A done and was empirically started on Augmentin for UTI. Today (3/29), her PCP called told her that urine was culture-negative for infection and that she should go to the ED for evaluation. Her symptoms today include fatigue, bilateral headache with mild photophobia, nausea with vomiting about once a day for the last week, decreased oral intake, and a non-productive cough that is slightly more than what she calls her smoker's cough. She doesn't think that her UOP has decreased, hasn't taken any new medications other than augmentin, takes no NSAIDs. She denies any fevers, chills, abdominal/flank pain, SOB, chest pain, dysuria.

 

PMH:

HIV-on Epzicom, atazanavir/ritonavir (CD4 471 and undectable HIV viral load 6/2011)Polyarthritis

Chronic sinusitis

Neuropathy

CAD

MI (s/p stenting x2 in 1/2011)

 

Meds:

Abacavir/lamuvidine 600-300mg po daily

Albuterol HFA prn SOB

ASA 325mg po daily

Azatanavir 200mg po daily

Clopidgrel 75mg po daily

Famotidine 20mg po daily

Losartan 25mg po daily

metoprolol ER 50mg po daily

Pravastatin 80mg po daily

Ritonavir 100mg po daily

 

Allergies:

Sulfa, codiene

 

PSH:

Appendectomy in distant past

 

FH:

non-contributory

 

SH:

Current everyday smoker, 1ppd/37 years

Very occasional drinker

no street drugs, never IVDU

HIV aquired from ex-husband

sexually active with boyfriend, uses condoms

 

PE:

(this pt was sent to our institution as transfer, so I did not perform the ED exam, but in sign-out it was that VSS, normal PE)

 

 

[VictoriaO]

To make things more interesting, I'll throw in her ED work-up:

Head CT: negative

CXR: negative

LP: negative, negative gram stain, nL protein

UA: gross hematuria, gross protien, many bacteria

BMP: Na: 140 K: 5.5 Cl: 116 CO2: 11 HCO3: 15 BUN: 70 Cr: 7.0 Gluc: 100

CBC: 5/11/30/170 (not exact, but in fairly normal range)

[ToppDog]

Did they redo the urine culture & sensitivity after seeing many bacteria on the micro UA? Get a cath'd urine specimen to rule out contamination? Did she get an IVP or cystoscopy?

[VictoriaO]

Yes, the ED straight-cathed her, I believe they did get 2 samples for C&S, the story gets more interesting after she is transferred to my hospital. I will post more info and labs later after my shift, feel free to d/dx

[EMEDPA]

any imaging studies done? renal u/s or noncontrast ct?

did her renal failure improve with hydration?

[Joelseff]

any imaging studies done? renal u/s or noncontrast ct?

did her renal failure improve with hydration?

 

Agreed...also when did she start HAART? How about a UPT?

 

Sent from my VEGAn-TAB using Tapatalk

[JCrownover]

Vitals? Any other labs? Additional info on your own ROS?

[Guest JMPA]

Smoker, ? painless hematuria, renal failure, I would certainly entertain the idea of TCC/RCC.

[xxbowiexx]

cancer is definitely on top of my list of DDx. Others are drug induced nephropathy, or anticoagulant (clopidogrel, ASA) use.

[Just Steve]

cancer is definitely on top of my list of DDx. Others are drug induced nephropathy, or anticoagulant (clopidogrel, ASA) use.

 

I'm with you. Painless hematuria without infection = cancer until proven otherwise.

[ventana]

nephrotic v nephritic syndrome......... casts or other findings on microscopy to indicate glom. damage/injury

 

concern for toxic levels of antivirals on famotidine (although likely not related) - liver function tests for albumin levels? Uric Acid serum level?

 

 

urine specific gravity? can she concentrate urine? is she fluid over or dry?

 

orthostatic? lung sounds wet? edema?

 

any jaundice or icterus? CVA tenderness

 

 

 

 

My first thought is that we need to decide rather the hematuria is a cause or result? is she suffering renal injury and leaking RBC's or is she bleeding in her upper/lower tract - casts will answer some of this for us as they would clearly be nephritic syndrome - if casts seen look for reason (I think there can be protein casts as well??) What is urine specfic gravity - again is this a renal cause or effect type question - if urine not concentrated thinking more toward glomular leak or injury - especially if elevate uric acid in light of the elevate CR (but less then 20:1 BUN/Cr showing she is not prerenal dehydrated)

 

ASO (antistrepolysin titer?? post strep glomulonephitis??)

 

 

many thoughts - great case!!

 

myoglobinuria? CPK? - thinking along the lines of rhabo or muscle injury from toxic levels of statin due to drug-drug interaction

[jmj11]

Certainly the horses would be a renal ca, but for a zebra did they do a aspergillosis antibiody

?

[RRivas2004]

Check for Lupus, and Wegners Granulomatosis. Order an ANA and an ANCA. Sounds like an autoimmune type deal vs RCC

[polarbebe]

Bladder CA?

 

"sign-out it was that VSS"

I believe if the bicarb is 15, likely loss from AKI then the respiratory compensation for blowing off CO2 would lead to tachypnea and probably not VSS as it was signed out to you (especially with a CO2 of 11). I wonder what her ABG shows?

[JCrownover]

Anything further on ROS or labs? Did you get that Renal US? VSS, but are they unremarkable?

[deborah212]

I also have the sense that this is autoimmune glomerulonephritis rather than CA given the rapidity in onset and associated systemic symptoms.

 

Would like to see a spun urine sediment and quantification of her proteinuria. Urine eosinophils though concomittant AIN unlikely. wondering if she's heading towards renal biopsy... Things that pop out to me are the cough for Goodpasture Syndrome and IgA nephropxathy with her HIV.

 

What does a pmhx of "polyarthritis" mean? Thinking again along rheum lines.

 

Did she have a DES in 2011? At least she's out a year... What are you doing with her ASA and plavix?

[RRivas2004]

Agree with Deborah, Def needs a biopsy if she's stable enough.

[VictoriaO]

Ok, so the story continues....

 

ED doc gives the pt 3L of crystaloid and a dose of ceftriaxone and transfers her to our tertiary center (anticipating she may need dialysis)

Night hospitalist accepting the pt notes she's well-appearing and in NAD (not tachypnic), does not appear dry or wet, no edema, lungs clear, no CVA tenderness, really no obvious no physical exam findings

Her initial labs at our facility are as follows (this is after her 3L)

ABG: 7.18/30/79/11 BE -16.3

Chem: Na 140 K 5.8 Cl 116 CO2 12 AG 16 BUN 58 Cr 6.52 Gluc 86 Ca 8.1 Phos 6.5 AST 15 ALT 12 Alk Phos 89 LDH 166 Bili 0.6 total prot 5.6 albumin 2.3 CK 31 lactate 0.5

CBC: 4.2/10.2/30.2/159 Diff unremarkable INR: 1.1

UA: Bloody, mod cloudy, large blood, 100 protien, nitrite neg, LE trace, WBCs 5-7, RBCs>100, few squamous epi, no crystals or casts

Urine Cr: 40.44 Urine Cl: 76 Urine microalbumin: 568 Microalbumin/cr ratio: 1279

Urine K: 17 Urine Na: 83

 

The pt is placed on Bicarb in D5 gtt, started on Cacarb po, given kayexelate and 10uR and D50, placed on tele and a renal US is set up for tomorrow morning. Plavix held in anticipation of possible dialysis line. Nephrology knows about the pt and they will see her in the morning. You're now the PA coming on in the am. What would you like to do next?

[RRivas2004]

First things, V/S and check her urine output in the AM. Need to know if those 3L made any urine. Repeat ABG, and get an EKG, we are compensating for her renal failure by giving bicarb and controlling the potassium with the kayexelate. Repeat CBC and CMP, how much blood is she losing? Will she need blood?

[VictoriaO]

Vitals have been stable overnight, afebrile, HR 60's-70s, BPs 120's-130's/80's, RR 16-20 stating 97% on RA

Pt is peeing pink urine like a champ, 1-2L out by early afternoon

EKG shows first-degree AV block, no peaked T's or other abnormalities, nothing noted on tele strip

Repeat K is 5.4, give 10u R with an amp of D50. Repeat Cr is 7.18 now, BUN 57, CO2 15. Continued bicarb gtt, gave second dose kayexelate

 

To flesh things out a little more, here is more history from the pt and her chart:

Pt really endorses feeling well prior to the hematuria, states that she's been on the same HAART regimen for over 5 years, has been stable and working at her job as a bar manager, last saw her HIV doc in June last year, CD4 in the 400's, viral load undetectable. She does endorse feeling "flu-ish" the past week, has had many sick contacts and endorses some malaise, fatigue, nausea w/ mild (once daily) emesis, some sinus complaints (has chronic sinusitis), HA (frontal, with sense of pressure, mild photophobia, no dizziness). No sore throat, no diarrhea, no fevers or chills. No dysuria, no abdominal pain or flank pain. Did endorse some lower back pain for several days that dissipated. Pt lives in a rural area on 5 acres with her brother, does not drink well water. Has been to the bahamas but not in the past 5 years, has a dog, some cows on the property that she does not interact with. Not recently sexually active, prior to this was with BF using condoms. When questioned further about arthralgias, pt states they really aren't that bothersome and she considers part of "getting old", reports it's mostly her knees, hips and shoulders and she does a lot of heavy lifting carrying trays in her job. Does not take NSAIDs, no recent CT scans or any OTC meds or herbs.

 

Was originally diagnosed with HIV in 1996, interestingly pt presented to the internal medicine clinic for evaluation of neuropathy prior to HIV diagnosis. Had a hx of tick bite in the mid-90's with a targetoid rash, had a hx of positive lyme titers but none at our institution. Pt was worked up extensively for neuropathy including heavy metals, auto-immune, etc. Per pt the neuroapthy is present in her thighs, and is really not that bothersome unless she gets into a hot tub. Pt was later diagnosed w/ HIV after her ex-husband was diagnosed with lymphoma. She was started on ART and was stable for several years until 2004 when she stopped coming to clinic, then she presented with dysarthrias, word salad, confusion, headaches, and lack of taste sensation. Her hospitalization notes that she had not taking her ART for the past year as she could not afford it. Her DC summary notes she presented with AKI with Cr of 3 that quickly resolved with hydration, she also had transaminitis that also resolved. Hep serologies negative. Pt underwent an EEG which showed some diffuse encephalopathy, her CSF had elevated protien and her head CT showed possible leukoencephalopathy. JC virus was never isolated from CSF, cryptococcus negative, at this time the pt CD4 was <50 and her viral load was (high, can't remember exact numbers). Per her primary HIV he thought her presentation fit more with AIDS encephalopathy than Progressive Multifocal Leukoencephalopathy. She amazingly recovered quite well from all of this on her current HAART therapy regimen and has been stable ever since other than some occasional nausea with up-titration of her meds as well as a hx of a eosinophilic rash during another up-titration back in 2004/5. Pt does have a hx of some chronic sinusitis and sinus HA, but her chart following this hospitalization is notable for very good compliance with her HAART regimen (pt was able to qualify for funding).

 

Oh, forgot to mention, urine Eos were negative, not that it's a super sen/spec test

[RRivas2004]

Apparently Lyme dz can cause kidney failure in dogs and it is allegedly possible in humans as well. Would be good to get a lyme titer on her. I still think this is autoimmune and she may need some steroid therapy. Did she receive her doxy? Even so Lyme can change its shape to lay dormant for long periods of time even after therapy.

[Joelseff]

Working DDX: RCC, Glomerolonephritis, HIVAN etc..

 

What is pt's race? African American?

 

Renal bx would be helpful and imaging?

 

Any recs from Nephro?

[VictoriaO]

Pt is a white female, over the weekend nephrology wants to see what her Cr will do, investigate meds (we decreased her atazanavir to 300mg per pharmacy as this can cause AIN). Forgot to mention no eosinophilia on diff. Urine spin over the weekend showed gross monomorphic reds, minimal casts.

 

Here is the renal ultrasound:

US KIDNEY & BLADDER: STUDY: US KIDNEY AND BLADDER 03/31/12

 

INDICATION:57 y/o woman with hx HIV presenting with acute kidney

injury and hematuria

 

COMPARISON: 2/24/4 ultrasound abdomen .

 

FINDINGS:

 

The kidneys are enlarged and echogenic. The right kidney measures

12.2 x 6.2 x 5 .1 cm, with a volume of 200 mL. The left kidney

measures 11.5 x 4.6 x 4 .5 cm, with a volume of 126 mL. Renal size

and hyperechogenicity of both increased compared to 2004. Mild

pelvocaliectasis is present on the left. No pelvocaliectasis on the

right. No calculus, mass or perinephric fluid is evident. Images of

the bladder are unremarkable.

 

IMPRESSION:

 

1. Bilateral renal enlargement and hyperechogenicity as can be seen

with HIV nephropathy, new since 2004.

 

2. Mild left pelvocaliectasis.

Lyme was not on our d/dx given that chronic lyme is not really supported in most ID circles (at least at our institution). We don't have any positive titers nor outside records, presumably she got a course of doxy after the tick bite.

[RRivas2004]

Well I'm plum out of ideas, drug vs immune, HIVAN, as stated by Joelseff...Did she go for biospy?

[ventana]

humm bladder obstruction leading to hydro?? sort of rules out CRI ..... I am out of ideas too - - - as a renal doc once told me "you just have to listen to what the kidney is telling you " but I think I am kidney deaf....