An 82-year-old woman presented to the emergency room after a fall while on anticoagulation. She denied dizziness, palpitations, or loss of consciousness before the event. Her past medical history was remarkable for coronary artery disease and deep vein thrombosis managed by inferior vena cava (IVC) filter and warfarin therapy. Physical examination findings were unremarkable, with no noted adenopathy or hepatomegaly. A laboratory workup revealed a white blood cell count of 6000 cells/mm3 (normal 4000-10 000 cells/mm3). Blood urea nitrogen and serum creatinine were 36 mg/dL (normal 7-22 mg/dL) and 2.34 mg/dL (normal 0.6-1.4 mg/dL), respectively. The patient's serum creatinine was elevated from her baseline of 0.90 mg/dL. In addition, her serum calcium was elevated to 15.7 mg/dL (normal 8.5-10.5 mg/dL): all other blood chemistries, including liver function tests, were within normal limits. Renal ultrasound revealed a 14-cm heterogeneous right renal mass. Subsequent noncontrast computed tomography (CT) of her chest, abdomen, and pelvis revealed several bilateral pulmonary nodules that were too small to characterize, thyroid nodules and the renal mass, which was shown to be causing a mass effect on the IVC, liver, and duodenum, with no definite extension into the right renal vein or IVC (Figure 1, Figure 2). She did have a prominent precarinal lymph node and some noticeable retroperitoneal and mesenteric lymph nodes, but none were enlarged by CT criteria. Fine needle aspiration of the thyroid nodules were negative for malignancy, and consistent with benign follicular nodule.
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Published online: July 16, 2012
Accepted: May 14, 2012
Received: April 2, 2012
Financial Disclosure: The authors declare that they have no relevant financial interests.
Published by Elsevier Inc.