Case Presentation:
A 34‐year‐old female with a history of MVP, 2 weeks postpartum, presented with left flank pain associated with nausea and vomiting. She did not take any medications and denied smoking or drug use. Family history was noncontributory. On examination, the patient was afebrile, hypertensive, with left CVA tenderness. Cardiac, pulmonary, and abdominal exams were benign, with no lower‐extremity swelling. A CT of the abdomen with contrast demonstrated bilateral renal infarctions. An EKG showed sinus rhythm, without events on telemetry. Laboratory studies revealed hematuria and elevated LDH. Urine toxicology and thrombophilia panel were negative. A TTE showed no thrombus but was significant for a PFO. Subsequent bilateral lower‐extremity Dopplers were negative. A renal angiogram revealed a 3‐cm aneurysm with partial dissection of the left renal artery consistent with fibromuscular dysplasia. No visible disease was noted on the right.
Discussion:
Bilateral renal infarction is a rarely reported disease. Nonspecific clinical findings make it difficult to diagnose. Most infarctions are discovered between 24 hours and 4 days. Clinical manifestations include severe pain, fever, and nausea. Hypertension is believed to be due to activation of the renin‐angiotensin system. Leukocytosis, hematuria, and elevated LDH are associated lab findings. Most renal infarction is caused by thromboemboli from atrial fibrillation with a mean age of 66 years. However, case reports show a broad differential, including paradoxical emboli, thrombosis, and vascular wall phenomenon, particularly renal artery dissection. Fi bra muscular dysplasia (FMD) has been highly associated with renal artery dissection. FMD usually presents between ages 20 and 40, and is female predominant. Risk factors include estrogen exposure, Irauma or stretching of the renal artery, and family history. Unlike atherosclerotic disease, infarction from FMD is associated with normal creatinine values and occasionally, hypokalemia from secondary hyperaldosteronism. For initial workup CT with IV contrast is sensitive, whereas echocardiography with contrast is essential to investigate embolic sources. Angiography remains the standard in diagnosis and evaluation of potential interventions. The optimal treatment for renal infarction is uncertain, given the absence of comparative studies. Reported approaches include anticoagulation, endovascular therapy (thrombolysis or thrombectomy, with or without angioplasty), and open surgery. Managemenl requires a multidisciplinary approach, with treatment guided by causative etiology, time of presentation, nature of arterial lesion, degree of hypertension, and renal function.
Conclusions:
The purpose of reporting this case is to explore the differentia] diagnosis and management of acute renal infarction in young patients without atrial fibrillation. Literature on this unique phenomenon is reviewed.
Author Disclosure:
J. Reyes, none; V. Oza, none; S. Thomas, none.