November 2023 Medical Image of the Month: Obstructive Uropathy Extremis

Figure 1. Video of CT angiography abdomen/pelvis, played caudal to cranial, obtained during assessment in the ED demonstrating obstructive uropathy with bilateral multiloculated urinomas leading to compression of the inferior vena cava. To view Figure 1  video in a separate, enlarged window click here.

Figure 2. A: CT angiography of the abdomen, axial plane, at the level of the renal veins demonstrating compression of the inferior vena cava (yellow arrow). B: CT angiography of the abdomen and pelvis, coronal plane, demonstrating bilateral multiloculated urinomas (blue brackets). To view Figure 2 in a separate, enlarged window click here.

A 71-year-old veteran presented to the emergency department with two-weeks of progressive back pain radiating to the abdomen associated low-grade fever, nausea, and new lower extremity edema. The family reported confusion. His medical history was significant for chronic prostatitis and low-grade prostate cancer on biopsy that was lost to follow-up eleven years ago. His only reported medications were aspirin 81 mg daily and naproxen 500mg up to four times a day for his pain.

Vitals were significant for a temperature of 36.1 C, initial blood pressure of 201/74, heart rate of 128/min, respirations at 18/min with a saturation of 97% on 2L NC. Physical exam demonstrated no difference in blood pressures between arms. No abnormal heart sounds. Clear breath sounds to auscultation bilaterally. Flank tenderness to percussion and significant abdominal tenderness over the epigastric and suprapubic region with 3+ pitting edema of the bilateral lower extremities. Screening labs were notable for critical values of a WBC of 43.5 K/mL and potassium of 7 mEq/L with a creatinine of 6.5 mg/dL. He was started on esmolol and hyperkalemia temporizing therapy with the decision made to obtain an urgent contrast enhanced computed tomography of the chest, abdomen, and pelvis.

Imaging confirmed a diagnosis of severe obstructive uropathy with heterogenous prostate with nonspecific small hypodensities, marked bladder distension, hydronephroureter with ureteral wall prominence, and bilateral perinephric multiloculated fluid collections with extension into the abdominal and retroperitoneal spaces leading to indentation of the inferior vena cava (Figures 1 and 2). A Foley catheter was urgently placed with 2.5L of urine immediately relieved and prompt response in blood pressure to 130/80, and resolution of pain, altered mentation, and nausea. He was started on vancomycin and piperacillin/tazobactam for empiric coverage with three percutaneous drains subsequently placed in the multiloculated fluid collections with purulent discharge expressed. Cultures of the output demonstrated no growth. His post-obstructive diuresis was managed with replacement Lactated Ringers’ solution at 75% of the rate of Foley output. He demonstrated complete improvement in leg swelling, heart rate, and WBC and creatinine normalized to 1.1 mg/dL with discharge to home in seven days with close urology follow-up for his prostatic abnormality.

This case of obstructive uropathy extremis, probable cystocerebral syndrome (hypertension, altered mental status, and bladder distension in the elderly), and bilateral urinomas leading to inferior vena cava syndrome is unique to the literature (1). The rupture of the renal fornices, the most delicate and purported “pressure check valve” of the renal conduits, can precipitate the formation of localized urinomas within the perinephric and retroperitoneal space, most commonly unilateral from ureteral or kidney stones or tumor related obstruction, rarely bilateral from bladder outlet obstruction (2). These urinomas, as seen in this case can exert a progressively escalating pressure on the contiguous inferior vena cava, which has been described as “inferior vena cava syndrome” (3). The implications of this pressure increase are manifold, encompassing the observed clinical manifestations ranging from lower extremity edema, worsening kidney perfusion, to hemodynamic instability (3). Management centers upon decompression of the obstruction, treatment of secondary infection with source control, and compensation for post-obstructive diuresis with generally favorable prognosis if recognized early in the clinical course.

Nathan Walton MD¹, Elizabeth Mata MD¹, Max Hart MD¹, Matthew Borchart MD²and Adnan Abbasi MBBS³

¹Internal Medicine Program, University of Arizona College of Medicine – Tucson

²Department of Medicine, Pulmonary & Critical Care, University of Arizona College of Medicine – Tucson

³Department of Medicine, Pulmonary & Critical Care, Southern Arizona Veterans Affairs Health Care System (SAVAHCS) – Tucson

References

1. Blackburn T, Dunn M. Cystocerebral syndrome. Acute urinary retention presenting as confusion in elderly patients. Arch Intern Med. 1990 Dec;150(12):2577-8. [CrossRef][PubMed]
2. Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int. 2011 Dec;108(11):1909-11; discussion 1912. [CrossRef][PubMed]
3. Lawrensia S, Khan YS. Inferior Vena Cava Syndrome. 2023 May 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. [PubMed]

Cite as: Walton N, Mata E, Hart M,  Borchart M, Abbasi A. November 2023 Medical Image of the Month: Obstructive Uropathy Extremis. Southwest J Pulm Crit Care Sleep. 2023;27(5):56-58. doi: https://doi.org/10.13175/swjpccs043-23 PDF

November 2023 Imaging Case of the Month: A Crazy Association

Parker J. Brown MD, Prasad M. Panse MD and Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Phoenix, Arizona

HPI: A 55-year-old man presents with a history of cough, poor appetite, low energy, and weight loss over the previous 6-10 months following COVID-19 infection 2 months earlier. 

PMH, SH, FH: The patient’s past medical history was positive for CVOID-19 infection 2 months earlier as well as pneumonia, not specified, in the previous year.

The patient’s past medical history was also remarkable for a 7-unit gastrointestinal hemorrhage approximately one year earlier following polypectomy for benign lesions in the transverse colon. During that hospital admission a complete blood count showed 1% blasts which prompted hematology consultation. The consulting oncologist felt the peripheral blasts were the result of a leukemoid reaction secondary to increased bone marrow stimulation owing to the patient’s acute anemia caused by the gastrointestinal hemorrhage. Macrocytosis and reticulocytosis was also noted and attributed to the same. Repeat complete blood count showed no blasts although some myelocytes, metamyelocytes, and polychromasia was noted for which follow up assessment was recommended. Serum B12 and folate levels were normal.

The patient had no prior surgeries.

The patient was not taking any prescription medications.

The patient is a non-smoker. He has no known allergies and drinks alcohol only socially and denied illicit drug use.

There was no significant family history.

Physical Examination: The patient’s physical examination showed his temperature to be 96.7°F with borderline elevated pulse rate of 95/min, a normal respiratory rate, and blood pressure of 118/67 mmHg. Room air oxygen saturation was 98%.

Initial Laboratory: A complete blood count showed a normal white blood cell count at 5.6 x10⁹/L (normal, 3.4 – 9.6 x10⁹/L), with 75% bands (normal, 50-75%). His hemoglobin and hematocrit values were 10.1 gm/dL (normal, 13.2 – 16.6 gm/dL) and 31.6% (normal, 38.3 – 48.6%). The platelet count was normal at 225 x 10⁹/L (normal, 135 – 317 x 10⁹/L). The patient’s serum chemistries and liver function studies were normal aside from mildly decreased total protein at 5.7 gm/dL (normal, 6.3-.9 gm/dL). The patient had an elevated anti-nuclear antibody titer at 1:320. SARS-CoV-2 PCR testing was positive.  

Radiography: Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography at presentation.

Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the second of fourteen pages).

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows marked cardiomegaly
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pleural effusion
5. Frontal chest radiography shows multifocal consolidation

Cite as: Brown PJ, Panse PM, Gotway MB. November 2023 Imaging Case of the Month: A Crazy Association. Southwest J Pulm Crit Care Sleep. 2023;27(5):47-55. doi: https://doi.org/10.13175/swjpccs046-23 PDF