2 patients on 2 consecutive nights from a Naval Medical Center.
Both were stone studies, which was a reasonable clinical suspicion since that is probably the most common cause of flank pain. Both of them also presented with elevated creatinine precluding contrast out of concern for contrast nephropathy.
As an aside, acetylcysteine has no protective effects on the kidneys in the prevention of contrast induced nephropathy. I do not know of any institutions who were actually using this on a regular basis but from time to time it pops back up as a prophylactic measure in CIN. This was recently commented on in up-to-date.
What made me notice this “pattern” if you will, was that perinephric stranding is fairly uncommon in the young military population in the absence of chronic disease or urolithiasis. On seeing the 2nd case on a consecutive night, I did some digging to find out whether the previous case was actually the night before and from the same institution. The biggest concern in my mind was whether there was an epidemiologic issue such as HUS-TTP.
My suspicion is that it turns out it is an epidemiologic issue but unrelated to infection. Both patients reported to the emergency department with flank pain and no trauma after vigorous physical training (PT) workouts. They did have hematuria. Creatinine was above 2.0 in both patients. Although CT is unreliable, they both seemed adequately hydrated (IVC distention).
I would love to hear follow-up on these cases as it seems that this is probably rhabdomyolysis with acute renal injury secondary to vigorous exercise. I cannot remember seeing such a close association however the most likely thing is that this happens often and I simply miss it because the patients are not imaged or other people take up the studies.
For me it is a reminder that military training is not a benign process. To create the outstanding fighting force, young men and women not only sacrifice the best years of their life, they endure physical and psychological hardship for the benefit of the homeland.
one of the drawbacks of the current job is that I rarely get feedback on cases and there are plenty of good cases. This was done for hip pathology but given the appearance of the sigmoid colon, I would place a greater than 70% probability that colorectal carcinoma is present which is probably asymptomatic.
In cases like these I typically recommend CT abdomen and pelvis with contrast and colonoscopy. In this case in particular, the CT will help assess the morphology of the hip which was the primary cause for obtaining the study.
Could it be diverticulitis or IBD? Sure. Would I want to assume such and more importantly…
Would I want that section of colon in my pelvis? — >
Lipomatous hypertrophy of the interatrial septum is an exaggerated growth of normal fat existing within the septum and is not a true tumor. Rather, it is a developmental disorder caused by expansion of adipose tissue trapped in the interatrial septum during embryogenesis. The septal hypertrophy may be as large as 2 cm in thickness and is seen primarily in older patients and in those who are obese.
It has been suggested that this disorder is associated with the presence of coronary artery disease in proportion to the degree of atrial septal thickness (possibly true in this case although the patient is a vasculopath).
Lipomatous hypertrophy of the interatrial septum is indistinguishable from lipoma except that the former occurs in the atrial septum with a typical distribution (generally sparing the fossa ovalis). In the absence of symptoms of atrial arrhythmias, heart block, or rare vena caval obstruction, they do not require resection.
Having never placed these myself, it must require a of lot hand wringing about where the screws are actually going. I have seen a screw perforate the T – cord from an operation in Greensboro, resulting in intractable pain.
For scoliosis patients, this is especially challenging since every level has a slightly different projection due to the curvature and rotation.
These cases give rise to so many questions such as what did the fluoroscopic view look like, did the patient get a pneumothorax, what is the tolerance of the pleura and lung to a penetrating screw?
I know from spinal procedures and joint injections that careful evaluation of the projection that can take minutes of fluoro is far better than the struggle associated with a bad approach.