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RENAL UNIT CASE 9 |
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Clinical History: A 33 year old man was admitted to the VA Hospital in for right flank pain and fever. Ten years earlier, during a War, a gun shot wound caused a spinal cord injury which resulted in paraplegia and urinary incontinence. Since that time he has had an indwelling Foley catheter. About 5 years prior to admission he had a episode of ureteral colic and passed a stone, which was not analyzed. Both before and after that episode he had urinary tract infections and since 1980 he had been taking Nitrofurantoin for prophylaxis of urinary infection. In the year before admission he developed increasingly frequent symptomatic infections with Pseudomonas, Proteus and E. coli strains. Flank pain was becoming more frequent and he often had fever. Also, he had little appetite and had lost 12 pounds in the past 3 months. Physical examination: BP = 135/80 mm Hg; R = 14/min, P = 92/min and T = 38.8°C. He had neurological evidence of spinal cord injury and tenderness in the right flank. Lab: Hct 38 %; WBC 10,800 /mm3, neutrophils and bands 80%, lymphocytes 15%, monocytes 5%. Creatinine 1.1 mg/dl. Urinalysis: Protein 1+, Sp. Gr. 1.013, pH 7.5, glucose negative. The sediment is shown in Figure 1a & 1b. Questions: 1. What does the sediment show? What are the things predisposing to urinary tract infections at the various times in his medical history, from the time of the injury to the present? 2. An excretory urogram was done and some of the films are shown on your slides. Figure 2a, 2b & 2c show before the dye injection (0 min), at 3 min after dye injection and at 6 min after dye injection respectively. What do you see? 3. Figure 3 shows the radionuclide renal scan. What is your interpretation? 4. What would you do next? 5. A right nephrectomy was done and the gross specimen is shown in Figure 4 and Figure 5. Figure 6 is a microscopic examination from the cortex and Figure 7 is a microscopic examination from the vicinity of a renal calyx. What are your diagnoses for the case as a whole? How do you interpret the weight loss? 6. Discuss the pathogenesis of the stone. In what other conditions do stones form? |
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