SESSION TYPE: Miscellaneous Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Fat emboli have been known as part a syndrome associated with pelvic or long bone fractures, and patients usually present with neurologic, hematologic, dermatologic, and respiratory manifestations. Other types of pulmonary emboli represent dislodgements from thrombi or lesions originating in the venous circulation.
CASE PRESENTATION: A 70 year-old non-smoker woman with a history of hypertension was evaluated for slightly worsening kidney function. Abdominal renal ultrasound followed by computed tomography (CT), showed a 12 cm left renal mass consistent with fat density (-69 Hounsfield Unit) and invasion of the left renal vein. Chest CT scan revealed a large pulmonary embolus of fat density within the right pulmonary artery. Left radical nephrectomy followed by histopathological examination demonstrated the diagnosis of benign angiomyolipoma (AML). The patient was discharged home on no anticoagulation. Follow-up chest CT scan 4 weeks later showed no extension of the pulmonary embolism.
DISCUSSION: AML rarely extends into the renal vein, inferior vena cava or up to the right atrium. Moreover, only four cases of renal AML were reported in association with fat emboli. They were all symptomatic with significant respiratory or cardiovascular manifestations and treatment varied from observation to surgical embolectomy. Tan, Yip (1) described a patient who presented with acute dyspnea two months post nephrectomy for AML and was found to have fat pulmonary embolus that diminished in size 4 months later. Turowski et al reported a 20 year-old patient that developed cardiac arrest secondary to fat pulmonary embolus that occurred intra-operatively during nephrectomy for AML. In addition, Shinohara et al encountered the worst-case scenario where an 83 year-old woman presented with acute hemodynamic shock and died a few days later. There are no reported cases in the literature of renal AML that was associated with asymptomatic fat embolus. Further literature review found no evidence to support the use of anticoagulation to treat pulmonary fat emboli. Our case is unique as the patient was asymptomatic and the diagnosis was based on the incidental finding of right lung base density on abdominal CT scan. Unless symptomatic, the long-term implication of diagnosing asymptomatic fat emboli remains unclear. Furthermore, when invading the renal vein or the inferior vena cava (IVC), renal AML should be surgically removed even if asymptomatic. Some surgeons elect to use temporary balloon occlusion of the IVC during renal carcinoma resection to prevent fatal intraoperative pulmonary emboli.
CONCLUSIONS: Benign renal angiomyolipoma with renal vein extension can be associated with incidental diagnosis of an asymptomatic fat embolism.
1) Tan YS, Yip KH, Tan PH, Cheng WS. A right renal angiomyolipoma with IVC thrombus and pulmonary embolism. International urology and nephrology. 2010;42(2):305-8. Epub 2009/07/18.
DISCLOSURE: The following authors have nothing to disclose: Kassem Harris, Elie Hatem, Rabih Maroun, Theodore Maniatis
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