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 mucous 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 level of 1.21 mg/dL. Her serum creatinine value in 2001 was 0.7 mg/dL. Cardiac enzymes were negative for acute coronary syndrome. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels 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 scan of the abdomen obtained in the ED showed inhomogeneous 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, leukocytosis (leukocyte count of 15,700/μL) developed. Her serum creatinine level was 1.24 mg/dL and D-dimer level was 550 μg/L (reference, <500). Her AST and ALT levels rose to 167 U/L and 87 U/L, respectively. Lactate dehydrogenase (LDH) level was markedly increased at 1053 IU/L (reference, 105 to 333). Bilateral lower extremity ultrasonography was negative for deep venous thrombosis. A 2D echocardiogram was notable for a left ventricular ejection fraction (LVEF) of 62%, mild left ventricular hypertrophy, and a severely dilated left atrium.
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