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Reprint requests: Chandy Ellimoottil, M.D., Department of Urology, Loyola University Medical Center, 2160 S. First Avenue, Fahey Center, Room 261, Maywood, IL 60153
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.
Figure 1Noncontrast CT scan demonstrating a large renal mass.
