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Abstract: FR-PO205

An Uncommon Cause of Gross Hematuria With Underlying Fibrinolysis Induced by Pulmonary Artery Leiomyosarcoma

Session Information

Category: Onconephrology

  • 1600 Onconephrology

Authors

  • Hikida, Hiroshi Dean, Mayo Foundation for Medical Education and Research, Rochester, Minnesota, United States
  • Chebib, Fouad T., Mayo Foundation for Medical Education and Research, Rochester, Minnesota, United States
Introduction

Renal arteriovenous (AV) fistulas are an uncommon cause of gross hematuria. In our case presentation, the patient’s hematuria rapidly, but temporarily, resolved with two courses of doxycycline. Ultimately, the patient’s renal AV fistula was embolized with resolution of the hematuria. This case elucidates an unusual cause of gross hematuria due to renal AV fistula and exacerbated by fibrinolysis caused by a rare malignancy in the pulmonary artery.

Case Description

Patient presented to a local clinic with gross hematuria with clots and severe throbbing bilateral flank pain radiating to the groin. He was thought to have prostatitis and was treated with doxycycline which resolved his hematuria but recurred after few days after completion. He presented to our hospital with Hbg 7.4 g/dL and persistent gross hematuria. Abdominal renal imaging and cystoscopy was unrevealing. His workup was consistent with idiopathic fibrinolysis with normal bone marrow biopsy. CT chest revealed nodular opacities but negative comprehensive infectious work up on BAL. The patient ultimately had a real biopsy performed after which he developed retroperitoneal bleeding that stopped after IR embolization of several bleeding pseudoaneurysms. Renal arteriogram showed evidence of arteriovenous (AV) fistula. His bleeding stopped after initiation of tranexamic acid. Three months later, he developed spontaneous hemoptysis and ipsilateral flank ecchymosis. Subsequent evaluation revealed a large right pulmonary artery mass with FDG-avidity, with ultrasound-guided endobronchial biopsy confirming high-grade pulmonary artery malignancy. He ultimately underwent surgical resection for which surgical pathology revealed high-grade pulmonary artery leiomyosarcoma. Following surgical resection, his coagulopathy improved, and he has had no recurrent bleeding events.

Discussion

Studies have shown that underlying malignancy is found in 10-20% of patients with gross hematuria and thus requires systemic evaluation. Diagnosis of renal AV fistulas often require a high-index of suspicion, as their symptoms can vary widely from asymptomatic to gross hematuria, flank pain, and an abdominal mass. Renal artery angiogram is diagnostic gold standard and is required for selective embolization of the fistula as was performed in our patient with a rare underlying malignancy.