A Case of Renal Infarcts Followed by Renal Hematoma: The Importance of Angiography in the Diagnosis of Polyarteritis Nodosa
- Glomerular Diseases: Case Reports
November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Trials
- Marnet, Erica, Bridgeport Hospital, Bridgeport, Connecticut, United States
- Sedaliu, Kaltrina, Bridgeport Hospital, Bridgeport, Connecticut, United States
A renal infarct (RI) may go undiagnosed given its non specific symptoms; abdominal or flank pain, nausea and vomiting. Classically, it is attributable to cardiovascular causes, such as atrial fibrillation (AF), or to coagulopathies. Frequently, however, no underlying etiology is ascertained. Polyarteritis nodosa (PAN) is a medium vessel vasculitis not associated with antineutrophil cytoplasmic antibodies. Biopsy demonstrating necrotizing arteritis is the gold standard for diagnosis, and when it cannot be secured, angiography is an important tool to establish the diagnosis, exhibiting aneurysms or segmental stenosis of intraabdominal arteries.
A 52-year old female, with a past medical history of abdominal pain with prior extensive work up, presents with acute on chronic abdominal pain, nausea, vomiting and 6 kg weight loss. Work up revealed a left RI. Telemetry was negative for AF, as a transesophageal echocardiogram for left ventricle thrombus. Her hospital stay was complicated by ongoing abdominal pain, repeated imaging showing a new large right RI. Hypercoagulable work up was negative. However, It was believed she was high risk for recurrent thrombosis, thus, initiated on Apixiban. After two weeks, she returns with abdominal pain and was discovered with a large right pericapsular hematoma with possible active bleeding. Given hemodynamic instability, she underwent a right renal angiogram that showed severe irregularity with multifocal areas of stenoses, dilatations and microaneurysms, also, large areas of devascularization, consistent with PAN. Hepatitis B sorology showed prior immunization. She was treated with pulse dose steroid therapy and IV cyclophosphamide (total of 5 infusions), followed by PO prednisone 1mg/kg. Her abdominal pain ultimately resolved and she experienced no further thrombotic events.
The underlying etiology of RI requires compressive investigation. Proper treatment warrants an evidence based practice. PAN is a rare entity, however usually complicates with RI. This case highlights the importance of prompt recognition, appropriate diagnostic investigation, and timely treatment.