Abstract: TH-PO188

From a Complicated Biopsy to an Unexpected Diagnosis

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Murad, Haris Farooq, Yale School of Medicine, New Haven, Connecticut, United States
  • Luciano, Randy L., Yale University School of Medicine, New Haven, Connecticut, United States
Background

Polyarteritis Nodosa (PAN) is a rare systemic necrotizing vasculitis targeting medium sized arteries and can involve any organ in the body except for the lungs. Arterial inflammation causes tissue ischemia and hemorrhage and may present with a wide spectrum of clinical manifestations ranging from neuropathies and rashes to renal failure and bowel ischemia. Renal failure is thought to be secondary to ischemia from rupture of microaneurysms. Diagnosis requires an integration of clinical,radiographic and pathological findings, but the presence of medium vessel microaneurysms can suffice in the absence of tissue confirmation. We present a case in which the diagnosis was made in unusual circumstances.

Methods

A 46 year old lady with non-cirrhotic hepatoportal sclerosis presents with a gradually uptrending creatinine over two years reaching 4.1mg/dL, worsening proteinuria up to 5.6gm/day and a urine sediment showing granular casts. Renal ultrasound showed bilateral echogenic kidneys and elevated velocities in renal arteries and the aorta. She underwent a renal biopsy which was challenging and on the second pass she had severe abdominal pain. A color doppler demonstrated a pulsatile jet originating from the lower renal pole. She immediately passed a large amount of blood from her urethra. An emergent angiography showed several aneurysms in the liver, kidney and spleen (see figure) along with two pseudoaneurysms, consistent with a diagnosis of PAN. Unfortunately the biopsy sample was insufficient for interpretation. Subsequent labs showed elevated inflammatory markers, negative rheumatoid factor,cryoglobulins, hepatitis B and C titers.

Conclusion

This case demonstrates that a complication from a kidney biopsy was able to provide an important, and previously unthought of diagnosis in a patient. In addition it highlights the safety concerns of patients with vasculitis undergoing biopsy.