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Case 296

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61-year-old female patient, referred to the emergency room complaining of left back pain, fever, dysuria and polaciuria seven days ago. It is known to be a carrier of nephrolithiasis and CRD (baseline Cr 2.7 mg / dL) and she is in regular use of sodium bicarbonate and calcium carbonate and also antiretroviral therapy (ART) once she is a HIV positive patient in clinical latency for 23 years showing undetectable viral load. At physical examination demonstrated good general condition, hydrated, afebrile, full pulses, cardiac frequence of 90 bpm, PA 140x90 mmHg, good peripheral capillary perfusion, eupneic, left flank pain. It was requested laboratory tests that revealed: slag elevation (urea: 169 mg / dL and creatinine: 6.32 mg / dL); metabolic acidosis (pH 7.20 and 17 mEq / L HCO3); leukocytosis with neutrophilia (total leukocytes: 16,190 / mm 3 and neutrophils 12,370 / mm 3) and urinary tract infection (UR: pyuria, Gram-negative Gram-negative bacilli and negative BK culture). The imaging study consisted of computed tomography (CT) of the abdomen presented by the patient upon admission to Hospital das Clínicas / UFMG.

Based on the available data and the radiological examination presented, what is the probable etiology of this case?

a) Urogenital tuberculosis with ureteral stenosis

25%

b) Crystalline blockade of antiretroviral

25%

c) Intratubular precipitation of calcium from diet

25%

d) Wilson's disease

25%
   

Image Analysis

Image 1: Computed tomography (CT) of the abdomen, axial reconstruction, renal level, with no use of an iodinated contrast agent. Left hydronephrosis (in red) associated with the presence of very small radiopaque concretion on the posterior border of the renal parenchyma (in blue). Right kidney presenting diffusely reduced dimensions and parenchymal retractions, without dilation of the collecting structures (in green)

 

Image 2: Computed tomography (CT) of the abdomen and pelvis, coronal reconstruction, renal level, with no use of an iodinated contrast agent. Left hydronephrosis (in red) and dilation and tortuosity of the ipsilateral ureter throughout its extension (in yellow). Right kidney with diffusely reduced dimensions, lobulated contours due to parenchymal retractions, without dilatation of collecting structures - alterations compatible with chronic pyelonephritic etiology (in green). 

Highlights

- Indinavir sulfate, present in ART, predisposes to crystallization and formation of radiolucent kidney stones, especially in conditions of volume depletion, hepatic insufficiency, renal insufficiency, urinary pH decrease, HCV/HBV coinfection and concomitant use of acyclovir or trimethoprim-sulfamethoxazole;

- The use of indinavir sulfate requires frequent monitoring for urinary tract infection and alteration of renal function periodically during the first six months of therapy and then every 2 years;

- The ultrasound of the kidneys and urinary tract is the initial examination of choice and identifies radiotransparent and radiopaque calculi;

- Treatment of nephrolithiasis associated with indinavir should be conservative, with hydration (at least 1.5L of liquid per day), pain control, monitoring of renal function and temporary discontinuation of the drug;

- CT scan of the abdomen and pelvis is also a first-line imaging test in the diagnosis of renal calculi.

References 

– Matlaga BR, Shah OD, Assimos DG. Drug-Induced Urinary Calculi. Rev Urol. 2003 Fall; 5(4): 227–231.

– Wise GJ, Marella VK. Genitourinary manifestations of tuberculosis. 2003, Urol Clin North Am 30: 111–121.

– Havlir DV, Barnes PF. Tuberculosis in patients with human immunodeficiency virus infection. 1999, N Engl J Med 340: 367–373.

– European Association for Study of Liver (EASL). Clinical Practice Guidelines: Wilson's disease. J Hepatol. 2012 Mar;56(3):671-85 full-text.

– Wiebers DO, Wilson DM, McLeod RA, Goldstein NP. Renal stones in Wilson's disease. Am J Med. 1979 Aug;67(2):249-54.

Author

Rafael Valério Gonçalves, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: rafaelvg[at]gmail.com

Wellerson Mayrink de Paula Júnior, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: wmpjr110196[at]gmail.com

Supervisor

Doctor Bruno Mello Santos Urologist, Professor of the department of Surgery of the Faculty of Medicine, UFMG.

E-mail: bruno[at]videourologia.com.br

Reviewers

Lucas José, Luísa Bernardino, Ariádna Andrade, Professor José Nelson Mendes Vieira and Professor Viviane Parisotto

Translated by

Giovanna Vieira Moreira, 6th year medical student at Universidade Federal de Minas Gerais.

Email: giovieiramoreira[at]gmail.com

Test question

(PUC-PR – MEDICAL CLINICS3RD YEAR OF MEDICAL RESIDENCY 2007) Which of the alternatives below characterizes the laboratory abnormalities found in a patient whose diagnosis is urinary tuberculosis:

 

a) Increased urinary density + Pyuria

25%

b) Hematuria + Leukocyturia

25%

c) Pyuria + Hematuria

25%

d) Decreased urinary density + Leukocyturia

25%

e) Presence of cylinders in the urinary sediment + Leukocyturia

25%
   

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