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Renal Infarction in the Setting of Undiagnosed Paroxysmal Atrial Fibrillation

Renal Infarction in the Setting of Undiagnosed Paroxysmal Atrial Fibrillation

A 73-year-old woman with a past medical history significant for gastroesophageal reflux disease, hypertension, diverticulosis, and a remote history of recurrent urinary tract infections presented to the emergency department (ED) with acute onset of nausea and vomiting. She admitted to at least 13 episodes of emesis over the previous 24 hours. She also complained of left upper quadrant pain that radiated to her left flank and noted fevers and occasional chills, but review of other systems was unremarkable. Home medications included ibandronate, lisinopril, and acetaminophen with codeine. She denied smoking and alcohol consumption.

On physical examination, she was afebrile, with a pulse of 84 beats/min and a blood pressure of 154/81 mm Hg. She was alert and in no acute distress. HEENT exam was significant for dry mucus membranes. Cardiovascular exam revealed a regular rate and rhythm without any audible murmurs. Her abdomen was soft, nondistended, and free of fluid wave or palpable organomegaly. There was some mild to moderate tenderness to palpation of the left upper quadrant and slight costovertebral angle tenderness but no discernible rebound tenderness, guarding, or rigidity. Bowel sounds were normoactive in all quadrants and no abdominal bruits were auscultated. Remaining exam was unremarkable.

Initial laboratory studies were notable for a serum creatinine of 1.21 mg/dL. Her serum creatinine value in 2001 was 0.7 mg/dL. Cardiac enzymes were negative for acute coronary syndrome. AST and ALT were 57 U/L and 53 U/L, respectively. Urinalysis was unremarkable and negative for hematuria. Blood and urine cultures revealed no growth. ECG in the ED showed normal sinus rhythm without any evidence of acute coronary syndrome. A contrast-enhanced CT of the abdomen performed in the ED showed inhomogenous uptake of contrast in the left kidney (Figure 1). CT also revealed diffuse diverticulosis of the descending and transverse colon without evidence of diverticulitis.


Figure 1 — Contrast-enhanced CT of the abdomen showing decreased uptake of contrast in the left kidney.

Empiric broad spectrum antibiotics were initiated because of concern for possible pyeloneprhitis. The following day, she developed a leukocytosis of 15 700 cells/μL, serum creatinine of 1.24 mg/dL, and a D-dimer of 550 μg/L (reference <500). Her AST and ALT levels rose to 167 U/L and 87 U/L, respectively. LDH was markedly increased at 1053 IU/L (reference 105 to 333). Bilateral lower extremity ultrasound was negative for deep venous thrombosis. A 2D echocardiogram was notable for an LV ejection fraction of 62%, mild left ventricular hypertrophy, and a severely dilated left atrium.

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