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An Unusual Presentation of Abdominal Aortic Dissection Mimicking Pyelonephritis FREE TO VIEW

Meghan Rane, MD; Vanessa Hoy, MD; Umbreen Arshad, MD; Shradda Goyal, MD
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SUNY Upstate, Syracuse, NY

Chest. 2013;144(4_MeetingAbstracts):327A. doi:10.1378/chest.1704109
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Abdominal aortic dissection can track into the renal arteries due to their anatomical location. Dissection of a renal artery leads to symptoms of lower back and flank pain mimicking a localized renal disease rather than a warning sign of a greater underlying pathology.

CASE PRESENTATION: A 28 year old male presented with a one day history of fevers and right flank pain. Initial labs of urinalysis and culture were negative. Standard intervenous antibiotics were given for suspected pyelonephritis, however fevers persisted. Computerized tomography (CT) confirmed the diagnosis of pyelonephritis with stranding surrounding the right kidney with an questionable "blush" lesion (image) which was indeterminate for extravasation of blood or an abscess. Urology service recommended conservative management. Over the next three days, clinically improved was noted, conversely the renal function declined. Fevers returned and the differential included renal abscess. Due to renal failure, CT with contrast was refused by the patient. Soon after, the patient had a seizure and subsequently shock. Stat labs returned with a dramatic drop in hemoglobin. Clinically, his abdomen became distended and developed jaundice. Surgery immediately took the patient to the operating room where an abdominal aortic dissection was found with two tears leading to massive hemorrhage in the retroperitoneal cavity. Both renal arteries appeared to be in various stages of dissection with the right kidney completely obliterated and the left kidney still intact. The patient passed away within minutes of the surgical intervention.

DISCUSSION: Spontaneous aortic rupture is associated with a mortality of 90%. In this case aortic dissection preceded the rupture, tracking initially into the right renal artery causing a hematoma within the renal capsule leading to flank pain. The intense stress of the dissection and hematoma formation led to fevers skewing the differential toward pyelonephritis despite negative urine studies. Renal artery dissection causes reduction of perfusion and leads to kidney failure. Thus with unresolving "pyelonephritis" with normal urine studies and radiological abnormalities, a differential of aortic dissection should be investigated. Any cause of aortic dissection can lead to the above complications, however in this case it is thought to be related to collagen vascular disease, genetic tests are pending

CONCLUSIONS: Abdominal aortic dissection involving renal arteries give rise to pyelonephritis-like symptoms that will not resolve to antibiotics. Without identification, death due to aortic rupture is imminent.

Reference #1: Richard P. Cambria, David C. Brewster, Jonathan Gertler, Ashby C. Moncure, Richard Gusberg, M.David Tilson, R.Clement Darling, Grahme Hammond, Joseph Megerman, William M. Abbott. Vascular complications associated with spontaneous aortic dissection Journal of Vascular Surgery - February 1988 (Vol. 7, Issue 2, Pages 199-209, DOI: 10.1067/mva.1988.avs0070199)

DISCLOSURE: The following authors have nothing to disclose: Meghan Rane, Vanessa Hoy, Umbreen Arshad, Shradda Goyal

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