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Critical Care |

A Rare Case of Paradoxical Renal Embolus Through Patent Foramen Ovale

Gaurav Shah*, MD; Farrington Laura, MD; Koyamangalath Krishnan, MD
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East Tennessee State University, Johnson City, TN


Chest. 2012;142(4_MeetingAbstracts):346A. doi:10.1378/chest.1389480
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Abstract

SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Isolated paradoxical renal embolism has been reported rarely in literature. We report a case of paradoxical unilateral renal embolus due to patent foramen ovale (PFO) in an otherwise healthy Caucasian female.

CASE PRESENTATION: A 42 year old Caucasian female was admitted to the hospital due to severe flank pain associated with nausea and vomiting for 4 days. Computed Tomography (CT) of abdomen without contrast done 2 days ago was without any abnormalities. Medical history was significant for hypothyroidism and migraine. She was taking Armour thyroid, oral contraceptives and topiramate. On examination, she had flank and left lower quadrant abdominal tenderness. Labs showed normal electrolytes, renal function and benign urinalysis. There was leukocytosis without any other evidence of infection. CT abdomen with contrast was done and showed left renal infarction. Hypercoagulable work up was ordered while patient was started on heparin and warfarin and later on warfarin alone after adequate bridging. Subsequently lower extremity venous Doppler ultrasonography was done, which was negative for deep venous thrombosis. Echocardiogram with bubble study was ordered which showed patent foramen ovale (PFO) with significant right to left shunt. Renal artery angiography was done which ruled out local causes like fibromuscular dysplasia, aneurysm or dissection. Closure of PFO was performed. Patient was later discharged on warfarin with follow up as outpatient in 1 week. On follow-up, patient was asymptomatic with hypercoagulable workup negative, hence warfarin was discontinued.

DISCUSSION: Paradoxical emboli due to PFO are known to result in cryptogenic stroke, but it is rarely reported to cause renal infarction. Cases reported show that patients with PFO have higher incidence of paradoxical emboli not only due to preformed thrombus, but also in some instances due to certain thrombogenic chemicals which are thought to get metabolized in lungs. Studies have reported increased incidence of re-embolization in patients with unrepaired PFO who already have suffered from embolic event. Repair of PFO in such individuals results in considerable symptomatic improvement as well as marked reduction in incidence of further paradoxical embolus.

CONCLUSIONS: We advise clinicians to have high index of suspicion to consider the diagnosis of renal infarction secondary to paradoxical embolus in a patient with history of PFO in the appropriate setting. Proper diagnosis and timely treatment can significantly reduce morbidity as well as serious complication like myocardial infarction, stroke, transient ischemic attacks and limb ischemia. Further research about possible thrombogenic chemicals which may be metabolized in lungs and results in increased incidence of paradoxical emboli formation should be considered.

1) Pubmed

DISCLOSURE: The following authors have nothing to disclose: Gaurav Shah, Farrington Laura, Koyamangalath Krishnan

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East Tennessee State University, Johnson City, TN

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