NYU Medical Grand Rounds Clinical Vignette

Neelja Kumar, MD PGY 3 October 20, 2010

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Chief Complaint

• 54 year old African American man presenting with left sided testicular pain for one week

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness

• The pain began one week prior to presentation, associated with testicular swelling and tenderness • The pain did not improve with over the counter medications so he presented to the emergency department

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History

• Past Medical History: • none • Past Surgical History: • none • Social History: • 20 pack-year smoking history, denies alcohol or drug use • Worked as a college professor • Family History: • none • Allergies: • No Known Drug Allergies • Medications: • None

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination

• General: healthy appearing, in no distress • Vital Signs: T: 98.3 BP: 226/121 HR: 78 RR: 14 O2 Sat: 99% on room air • Left testicular tenderness to palpation • Trace non pitting edema in lower extremities to knees bilaterally • Remainder of Physical Exam was normal

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings

• CBC: Hemoglobin/Hematocrit: 11/31 •

Remainder of CBC was within normal limits

• Basic Metabolic panel: BUN/Creatinine: 36/2.3

•

Remainder of basic was within normal limits

• Hepatic panel: within normal limits • Urine Analysis: coarse granular casts, 3+ protein, 5-10 red blood cells

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings

• Protein to creatinine ratio 1.7; equivalent to 1.7g per day • Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus negative • C3, C4 normal • ANA negative • Double Stranded DNA negative

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies

• Electrocardiogram: normal sinus rhythm with left ventricular hypertrophy • Testicular ultrasound: mildly complex bilateral hydroceles

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Working or Differential Diagnosis

• Orchitis • Stage 3 Chronic kidney disease secondary to hypertensive nephrosclerosis

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Course

• Hospital Day 1: – The patient was started on ciprofloxacin for presumed orchitis – Nicardipine drip initiated for hypertensive emergency • Hospital Day 3: - Kidney ultrasound performed demonstrated increased cortical echogenicity bilaterally

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Course

• Hospital Day 5: – Testicular pain resolved • Hospital Day 7: - Given renal failure and findings on renal ultrasound, a renal biopsy was performed

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Renal Biopsy

Duplication of elastic lamina in interlobular artery Hematoxylin and Eosin Stain: sclerosis with hyalinosis

Periodic acid-Schiff stain: segmental sclerosis and adhesion to Bowman’s capsule

Renal Biopsy

Final Diagnosis

• Hypertensive nephrosclerosis with secondary Focal Segmental Glomerulosclerosis.

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