HDCN Mini Grand Rounds

Hematuria and Flank Pain in a Young Woman

From: Stephen Fishbane MD
Winthrop-University Hospital and SUNY Stony Brook School of Medicine
Department of Internal Medicine
Mineola, NY

Case Report

A 24 year old woman was referred for hematuria.

She first came to medical attention 8 years prior to admission, when she was started on oral contraceptives for menstrual irregularities. Five years later the pills were discontinued. Two months after discontinuation of contraceptives, and 3 years prior to the present time, she first developed the abrupt onset of left flank pain and nausea. At that time she was found to have microscopic hematuria and was believed to have renal colic. Therapy was initiated with fluids and analgesics, and the pain resolved within 12 hours. An intravenous pyelogram demonstrated decreased function and excretion of the left kidney, but no stones. A renal ultrasound was normal, with the right kidney measuring 11 cm, and the left kidney measuring 12 cm. One week thereafter the patient again developed left flank pain, this time accompanied by urine the color of "coca-cola."

Over the next three years, left flank pain was present on most days, with varying intensity. The pain was described as dull in quality, always on the left, with no radiation. There was associated nausea and occasionally vomiting. The patient's urine was usually orange to brown in color. Several urologic procedures including 2 cystoscopies and two intravenous pyelograms were negative. The patient was now being seen for evaluation of these persistent symptoms.

The patient took no medications and did not smoke, drink alcohol, or use drugs. Despite the pain, she was very functional and was currently a second year law student.

Physical examination

BP 100/70 Pulse 64 Afebrile
HEENT PERRLA, EOMI
Skin No lesions
Lungs Clear
Cor normal
Abd normal
Back Marked costovertebral tenderness, left side only
Ext No edema
Neuro Normal

Laboratory values:

Na 139 // K 3.9 // Cl 106 // Bicarb 24
BUN 9 // Creatinine 0.6

WBC 7K // Hct 37% // platelets 189 K

Urinalysis:
Specific gravity 1.020 // pH 5.0 // Heme 3+ // Protein negative
Sediment 20 RBCs/ hpf // 2 RBC casts noted

Discussion questions

1. Would you recommend that a renal biopsy be performed:

Yes
No

2. What do you believe to be the most likely diagnosis?

UROLOGIC
a. Nephrolithiasis
b. Malignancy
c. Other urologic diagnosis
NEPHROLOGIC
d. Thin basement membrane disease
e. IgA Nephropathy
f. Alport's syndrome
g. Loin pain hematuria syndrome
h. Lupus nephritis
i. Post-infectious nephritis
j. Vasculitis
k. Other nephrologic diagnosis

CONTINUE

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