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Carbon monoxide (CO) poisoning is a very common reason for emergency ward admission, with symptoms varying from a simple headache and dizziness to severe neurological and cardiac impairment. We report here a rare clinical presentation of CO intoxication manifested by a severe cardiac impairment with intracardiac thrombus formation, acute limb ischemia, renal infarction, and carotid artery thrombosis. There have been initial reports of thromboembolic events in acute CO poisoning with intracardiac thrombosis being sparsely reported. Contrary to venous thromboembolism, arterial thromboembolism in CO poisoning seems to be extremely rare. To the best of our knowledge, this is the first report in recent literature of a combined intracardiac thrombosis and multiple arterial thromboembolism induced by CO poisoning.

Acute renal infarction (ARI) is an uncommon disease and delayed diagnosis or misdiagnosis often leads to rapid deterioration of the patient. As patients with atrial fibrillation and left atrial myxomas are at risk of developing ARI due to cardiogenic thromboembolism, it is pivotal for clinicians to make a correct diagnosis and start a timely treatment. The present study reported on the case of a 68-year-old man who suffered from ARI secondary to thromboembolism associated with atrial fibrillation and left atrial myxomas. His renal function deteriorated rapidly after the onset of the attack. He was treated with anti-coagulant agents with excellent results. Classical anti-coagulation therapy remains to be the effective and safe treatment of ARI.

Renal infarction is a rare clinical entity that is not easily detected by low-sensitivity ultrasound. We herein report a case of dermatomyositis with renal infarction detected during corticosteroid therapy. The patient was followed up for 18 months. A woman who was clinically diagnosed with dermatomyositis complained of severe pain in the right flank of the low back and abdomen, accompanied by nausea and vomiting during corticosteroid therapy. Based on the findings of routine blood tests, abdominal X-ray radiography, and abdominal ultrasound, the patient was diagnosed with acute gastroenteritis and treated with levofloxacin. However, her symptoms were not relieved. Abdominal contrast-enhanced computed tomography revealed renal infarction. Clinicians should be alert to the occurrence of thrombosis, especially when it manifests as vasculitis in patients with rheumatic disease who complain of severe abdominal pain, because it may suggest the presence of renal infarction.

Introduction Anabolic-androgenic steroid (AAS) use and testosterone therapy have been well established risk factors for the creation of a pro-thrombotic state, and to precipitate formation of thromboemboli in individuals already predisposed to thrombosis. Case report Here, we present the case of an amateur bodybuilder, with a negative thrombophilia workup, who experienced primary renal infarction while using the AAS trenbolone acetate and testosterone, as well as a subsequent renal infarction while anticoagulated with apixaban. Discussion The development of subsequent infarctions in an anticoagulated patient with discontinued recreational steroid use poses a unique situation and challenges the current understanding of a thrombophilic state associated with steroids. The lifetime prevalence of anabolic steroid use is estimated to be 1% in the male population in the United States which is significant. Conclusion Further understanding and recommendations of appropriate anticoagulant should be further elucidated to appropriately medically manage patients from this confounding social and medical history., Highlights • Consideration of earlier CT study with contrast. • Thorough history taking including gym supplements. • The use of NOACs. • The need for further understanding of how anabolic steroids affect coagulation. • Educating patients using anabolic steroids regarding the risks of continued use.

A 62-year-old man was referred to our hospital due to acute-onset severe left lumbar pain. Computed tomography of the abdomen revealed a nonenhancing area in the left kidney with renal artery occlusion. Hyperhomocysteinemia, which is known as a risk factor of cardiovascular and thrombotic diseases, was also diagnosed. We performed percutaneous transluminal renal intervention using an aspiration catheter, and started the replacement therapy for folic acid and vitamin B deficiencies in addition to anticoagulant therapy. With improvement of blood perfusion in the left kidney, the patient was discharged after 15 days. In this patient with renal infarction, hyperhomocysteinemia may have been responsible.

Background/Aims: This study aimed to investigate the incidence and risk factors for acute kidney injury (AKI) and chronic kidney disease (CKD) in patients with renal infarction. Methods: A single-center retrospective study was conducted from January 2005 to December 2013. Baseline and clinical characteristics of the enrolled patients with renal infarction were evaluated and analyzed according to the presence of AKI and CKD. In particular, predictors for AKI and CKD were determined using logistic regression analysis. Results: Of the 105 patients included in present study, 41 (39.0%) patients had AKI. A total of 80 patients were followed up for 2 years after hospital discharge. Among these patients, 27 (33.8%) patients had CKD. In the multivariate analysis, the predictors were mean blood pressure (odds ratio [OR] 1.062, 95% confidence interval [CI] 1.015-1.112, p = 0.009) and bilateral involvement (OR 4.396, 95% CI 1.096-17.632, p = 0.037) for AKI, and AKI (OR 14.799, 95% CI 4.173-52.490, p < 0.001) and old age (OR 1.065, 95% CI 1.016-1.116, p = 0.009) for CKD. Conclusions: Physicians should pay attention to the development of AKI and CKD after renal infarction and follow patients over a long term.

Spontaneous renal artery dissection is a rare cause of renal infarction and can be a diagnostic challenge at times, necessitating high index of suspicion. Other common underlying causes, especially thromboembolic phenomena, need to be considered and investigated first before making this uncommon diagnosis with vascular imaging studies. Very few cases did report strenuous exercise as a predisposing factor for the development of spontaneous renal artery dissection, but we believe that sexual intercourse has not been reported before as an underlying precipitating etiology. We report a case of a young male who presented with renal infarction that started during sexual intercourse and was found to have an angiographically proven renal artery dissection.

Key Clinical Message Symptoms associated with numerous diseases can be indistinguishable from those of the urinary system disorders because receptors of many visceral organs as well as the body wall transmit sensation through pain fibers shared with the kidneys. Disregarding important family background of genetic disorder can be detrimental for some patients.

Introduction Vasculitis is a heterogeneous group of autoimmune disorders having multisystem involvement. In many cases, the neurological disorders have an atypical clinical course or even an early onset, and the healthcare professionals should be aware of them. Case description We report a case of 57-year-old Asian male without any significant past medical history admitted under the urology department. He had presented with abdominal pain and fever and was being treated for presumptive pyelonephritis (on antibiotics). He was referred to rheumatology when he developed severe unilateral headache on right side with significant scalp tenderness. Headache involved temporal and fronto-parietal-occipital area with no jaw claudication or any significant visual disturbance. There was no limb claudication or polymyalgia symptoms. On examination he had new onset hypertension (BP:174/94mmHg), rest of the systemic examination was normal with no bruit. Musculoskeletal and skin examination was normal. Investigations included CRP of 204, hemoglobin 133, white cell count 15.2 (neutrophils: 12.06), creatinine 118 (eGFR 59). Liver function: normal. Urine dip: Normal and blood/urine culture: negative. Immunological profile and viral screen was negative. Urgent CT head was done for severe headache which was normal. Patient was referred to rheumatology with provisional diagnosis of giant cell arteritis due to headache and raised inflammatory markers. On reviewing his CT abdomen, the renal parenchyma showed symmetrical well demarcated bilateral involvement which was more in favor of renal infarct rather than pyelonephritis. CT angiography of abdomen was requested which showed multiple vessel involvement including mesenteric artery and bilateral renal arteries with beaded appearance and stenosis. MR angiogram showed 6mm aneurysm of PICA with stenosis of P1 segment of PCA. Currently he is being screened for ADA2 deficiency. During his stay his renal function deteriorated, not responding previously to antibiotics. He was started on methylprednisolone pulse and antibiotics stopped in view of worsening liver function. On day 3 of methylprednisolone pulse he had significant improvement of his headache with stabilization of renal and liver function. Our plan is to start him on steroid sparing therapy based on the ADA2 levels. Discussion The classification of vasculitis is still unsatisfactory as the patho-genetic mechanisms have not been fully understood. Existing criteria classify based on predominant vessel involvement but there is still some overlap between them. The prevalence of CNS involvement in medium vessel vasculitis ranges as widely as 2-10% and does not usually occur until late in the course of the disease. The most commonly reported CNS manifestation is diffuse encephalopathy, followed in frequency by focal deficits and seizures. Intracranial aneurysms are rare with around 15 reported cases usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. Treatment guidelines are still not clear and most are treated conservatively by medical management. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported Deficiency of ADA2 (DADA2) has been recently recognized first molecularly described monogenic vasculitis having biallelic hypomorphic mutation in ADA2 gene. CNS involvement is one of the main features of DADA2 which presents with a wide spectrum of clinical manifestations ranging from systemic inflammation to cutaneous or visceral PAN like vasculopathy and early onset stroke. Our patient had presented with primary CNS and renal involvement with impending rupture aneurysm. Timely control of inflammation is pertinent in such cases with remission induction and maintenance to prevent stroke. Although cyclophosphamide is still used in such cases DADA2 usually require anti-TNF therapy. Our patient had good response to primary steroid therapy. Key learning points Acute GCA-like neurological presentation of medium vessel vasculitis with cerebral involvement is rare. If not recognised in a timely fashion, it can lead to sub-arachnoid haemorrhage which is the most common presentation of such cases. DADA2 is a recently recognised entity that presents with stroke and vasculitis/vasculopathy and responds to anti-TNF therapy. Conflicts of interest The authors have declared no conflicts of interest.

Constituting less than 25% of all renal artery dissections (RAD), isolated spontaneous renal artery dissection (SRAD) is a rare diagnosis that can cause subsequent renal infarction with impairment. The majority of SRAD cases are idiopathic. Management ranges from conservative, medical to endovascular, and surgical repair. We report a case of a young female on multiple medications who presented with SRAD. She presented with acute abdominal pain and was found to have isolated spontaneous renal artery dissection. The etiology of this patient’s isolated SRAD could possibly be pinned down to her multiple stimulant medications used after the major known causes were ruled out.

Complete heart block (CHB) and acute renal infarction (ARI) are both uncommon diseases and seldom encountered in the clinical practice. We describe a rare case of pre-existing left bundle branch block, presenting simultaneously with CHB and ARI. The possible mechanism depends on prior presence of either CHB or ARI. If ARI occurs first, severe pain and embolism may enhance the vagal tone resulting in decrease in the heart rate and transient intraventricular conduction interruption, which subsequently causes CHB. The opposite scenario, CHB preceding ARI, is also possible. CHB can be physiologic and transient, with higher risk of development in the circumstance of pre-existing conduction system disturbances. Patients with CHB are predisposed to formation of thrombi and thromboemboli, giving rise to ARI. In conclusion, awareness and timely identification of the clinical manifestations of these two diseases may facilitate early diagnosis and prompt management.

Resumen: Introducción: El infarto renal es una entidad poco frecuente y está sub-diagnosticada por lo que para su diagnóstico se necesita un alto índice de sospecha clínica. Objetivo: Determinar las características clínicas y paraclínicas más frecuentes en el infarto renal, destacando la repercusión en la función renal. Metodología: Se realizó una revisión sistemática de serie de casos en PUBMED y SciELO con los términos: “renal infarction” y “renal infarct”. Se estudiaron variables: demográficas, clínicas y paraclínicas. En el caso de las variables paraclínicas se analizó el porcentaje de pacientes con valores elevados de cada una de las mismas. El análisis estadístico fue realizado con EPI INFO 7. 2. Resultados: Los síntomas y signos más frecuentes fueron oliguria, dolor en flanco y abdominal, nauseas, fiebre y vómitos. Los parámetros paraclínicos alterados fueron: LDH, PCR y glóbulos blancos. Se constató injuria renal aguda en 30.8% de los pacientes, la progresión a enfermedad renal crónica se observó en 17.3% y la progresión a enfermedad renal terminal se observó en 5.2% de los pacientes. Discusión y conclusiones: La determinación de las características clínicas y paraclínicas más frecuentes del infarto renal, se pueden utilizar para disminuir el retraso diagnóstico, lo que tiene consecuencias terapéuticas. Abstract: Introduction: Renal infarction is a rare entity and is under-diagnosed, so a high index of clinical suspicion is needed for its diagnosis. Objective: To determine the most frequent clinical and paraclinical characteristics in renal infarction, highlighting the impact on renal function. Methodology: A systematic review of a series of cases was carried out in PUBMED and SciELO with the terms: "renal infarction" and "renal infarct". Variables were studied: demographic, clinical and paraclinical. In the case of paraclinical variables, the percentage of patients with high values of each of them was analyzed. The statistical analysis was performed with EPI INFO 7. 2. Results: The most frequent symptoms and signs were oliguria, flank and abdominal pain, nausea, fever and vomiting. Paraclinical parameters altered were: LDH, CRP and white blood cells. Acute renal injury was found in 30.8% of patients, progression to chronic kidney disease was observed in 17.3% and progression to end-stage renal disease was observed in 5.2% of patients. Discussion and conclusions: The determination of the most frequent clinical and paraclinical characteristics of renal infarction can be used to reduce the diagnostic delay, which has therapeutic consequences. Resumo: Introdução: O infarto renal é uma entidade rara e é subdiagnosticada, portanto, um alto índice de suspeita clínica é necessário para o seu diagnóstico. Objetivo: Determinar as características clínicas e paraclínicas mais frequentes no infarto renal, destacando o impacto na função renal. Metodologia: Uma revisão sistemática de uma série de casos foi realizada em PUBMED e SciELO com os termos: "infarto renal" e "infarto renal". As variáveis foram estudadas: demográficas, clínicas e paraclinicais. No caso de variáveis paraclínicas, foi analisada a porcentagem de pacientes com valores altos de cada um deles. A análise estatística foi realizada com o EPI INFO 7. 2. Resultados: Os sintomas e sinais mais frequentes foram oligúria, dor no flanco e abdominal, náusea, febre e vômitos. Parâmetros clínicos alterados foram: LDH, PCR e glóbulos brancos. A lesão renal aguda foi encontrada em 30,8% dos pacientes, a progressão para doença renal crônica foi observada em 17,3% e a progressão para doença renal terminal em 5,2% dos pacientes. Discussão e conclusões: A determinação das características clínicas e paraclínicas mais frequentes do infarto renal pode ser utilizada para reduzir o retardo no diagnóstico, o que tem consequências terapêuticas.

Varón de 91 años, con fibrilación auricular paroxística de siete años de diagnóstico, en tratamiento anticoagulante irregular, con abandono total de anticoagulante orales desde hace cuatro meses. Acudió a la emergencia por hematuria, fiebre y dolor lumbar. A 91-year-old man with paroxysmal atrial fibrillation of seven years duration, on irregular anticoagulant treatment, that stopped the oral anticoagulant therapy four months ago. He attended the emergency room due to hematuria, fever and low back pain. The image study revealed multiple infarcts in both kidneys.

Spontaneous renal artery dissection is a rare disease and an uncommon cause of renal infarction. The patient was a man who presented to the emergency room with sudden-onset right flank pain. Computed tomography revealed right renal infarction; thus, anticoagulation was initiated. Renal angiography revealed luminal narrowing of the segmental artery to the superior pole of right kidney without a dissection flap or false lumen. We stopped anticoagulation due to a lack of evidence of thrombi or luminal narrowing of the dissected vessels. When patients present with acute flank pain, it is important to suspect renal infarction and to perform a correct diagnostic workup, even when the patient shows normal urinalysis results and a normal LDH value.

A 12-year-old female neutered Jack Russell terrier was presented for further investigation of an acute two-day history of lethargy, inappetence and vomiting. Mild increase in urea and amylase and positive cPLI (Canine pancreatic lipase immunoreactivity) ELISA were present. Abdominal ultrasound revealed an irregular, heterogeneous and diffusely hypoechoic pancreas. Severe pancreatitis with secondary peritonitis was diagnosed. Supportive treatment was started, but the patient developed paradoxical vestibular syndrome. MRI was declined and the patient was euthanased. On histopathological examination renal infarction with evidence of thrombosis and focal cerebellar infarction were present. It is well documented that a hypercoagulable state is a known complication of severe pancreatitis. To the authors’ knowledge this is the first description of suspected thromboembolism secondary to pancreatitis resulting in neurological signs in a dog.

WOS: 000454144600011 Splenic and renal infarctions are embolic conditions which usually occur secondary to cardiac problems, thromboembolic systemic diseases, and infectious conditions such as sepsis. Trauma is a relatively rare cause of visceral infarctions. Traumatic segmental renal infarction associated with total splenic infarction is extremely rare. For detecting these visceral infarctions, contrast-enhanced computed tomography is essential, and a very careful examination is required for detecting very small infarctions and excluding total visceral infarctions. In isolated splenic or renal infarctions secondary to trauma, the common contrast-enhanced computed tomography findings are wedge-shaped or segmental hypodense areas in kidneys or spleen and rarely total visceral infarctions. Usually, intraperitoneal or retroperitoneal fluid collection which corresponds to bleeding from kidney or spleen is not seen in such cases. Also, the lack of evidence of active extravasation from renal/splenic arteries and pseudoaneurysm or dissection is an important finding of isolated traumatic splenic or renal infarctions. Because total infarctions can be misinterpreted in some cases, differences in density between intra-abdominal organs allowed by computed tomography must be carefully examined. Intestinal infarctions, the other abdominal injuries, pulmonary injuries, and pelvic or thoracic bone fractures usually accompany traumatic renal or splenic infarctions. In this report, we present contrast-enhanced computed tomography findings of a multitrauma pediatric case of traumatic total splenic and bilateral segmental renal infarction by reviewing the literature.

Pheochromocytomas have been described to be associated with renal infarction in a few sporadic cases. The underlying pathophysiologic mechanisms are catecholamine-induced vasospasm and direct compression or invasion of the tumor on renal artery or its branches. However, renal infarction caused by extra-adrenal pheochromocytoma is rarely reported. We describe an unusual case of benign extra-adrenal pheochromocytoma complicated with left renal infarction by severe vasospasm.

Fibromuscular dysplasia (FMD) is a vascular disease characterized by abnormal arterial wall architecture, usually visualized angiographically as the classic “string of beads” sign. We present the diagnostic dilemma of a 51-year-old woman admitted for a spontaneous renal infarct, with initial examination and investigations equivocal. She was consequently assessed for thromboembolic and vasculitic disease, before proceeding to digital subtraction angiography (DSA). This invasive method elucidated an area of focal FMD, previously not seen on computed tomography angiography (CTA). This is unusual due to CTA's high sensitivity and specificity but could be attributed to the less common subtype of FMD which requires combined imaging modalities to arrive at a diagnosis. Hence, there may be a role for the dual use of CTA and DSA in young patients presenting with a spontaneous renal infarct in the absence of other diagnoses.

Renal infarction is a rare emergency and the estimated incidence is extremely low according to the literature. In addition, simultaneous bilateral renal infarction was only about 20% in these rare cases. Herein we reported a case of acute renal failure related to bilateral renal infarction and successfully treated by endovascular therapy including angioplasty and catheter-directed thrombolysis. His renal function also significantly improved after the intervention. This rare case reminds physician that early endovascular therapy might improve renal function and result in better renal outcome for patients with simultaneous bilateral renal infarction.

Granulomatosis with polyangiitis (GPA) is a small-vessel vasculitis that is highly associated with anti-neutrophil cytoplasmic antibodies. GPA carries an increased risk of organ infarction, but renal infarction is rare. We herein describe a case of multiple renal infarctions caused by GPA. A 66-year-old man presented with hearing loss, nasal discharge, fatigue, and weight loss for several months. Cross-sectional contrast-enhanced computed tomography images revealed multiple low-attenuation areas in both kidneys. He subsequently developed fever and impaired renal function. Blood serum was positive for cytoplasmic anti-neutrophil cytoplasmic antibody and a renal biopsy showed granulomatous necrotizing vasculitis. He was diagnosed with GPA and treated with high-dose corticosteroids, plasma exchange, and cyclophosphamide. The patient ultimately entered clinical remission.

Resume Introduction L’infarctus renal est une pathologie rare, aspecifique souffrant d’une difficulte diagnostic, avec un risque d’insuffisance renale. Methodes Sur une periode de 24 mois (1 mars 2013–28 fevrier 2015), nous avons recense les patients signales comme presentant un infarctus renal, hospitalises en nephrologie, cardiologie ou medecine interne. Nous avons rapporte facteurs de risques cardiovasculaires, presentation clinique, biologique et scannographique. Un suivi prospectif a ete propose a 6 mois. Resultats Nous avons retrouve 11 cas representant 0,006 % des passages aux urgences, et un cas admis directement. Les signes cliniques sont apecifiques et le diagnostic n’a pas ete evoque a la prise en charge initiale, l’angioscanner redressant le diagnostic, avec un delai median de 3 j. Les etiologies regroupent 5 dissections, 4 embolies, une arterite canabinoide, une thrombose atheromateuse, une stenose postradique. Le traitement a consiste en une anticoagulation ( n = 7) avec antiagregant ( n = 1) ou antiagregant en relais ( n = 2), ou antiagregant seul ( n = 2). Deux patients ont beneficie d’une revascularisation et deux ont presente une insuffisance renale aigue secondaire. On retrouvait frequemment une elevation des LDH (4/5 valeurs disponibles) initialement ; un syndrome inflammatoire, une hypokaliemie et une elevation de la pression arterielle a 48–72 h. A 6 mois, un seul cas d’insuffisance renale sequellaire, une seule recidive. Conclusion L’infarctus renal souffre d’un retard diagnostic, et doit etre evoque devant toute douleur lombaire aigue. Un dosage des LDH complete peut orienter le diagnostic, confirme par l’angioscanner. L’association syndrome inflammatoire–hypokaliemie peut permettre de redresser le diagnostic.

Kidney infarction is an uncommon thromboembolic complication of atrial fibrillation (AF). Diagnosis of this condition can be challenging due to its rarity and the fact that its presentation is associated with a multitude of other pathologies. No treatment guidelines have been established so far; however, multiple modalities have been employed, including systemic thrombolytics, intra-arterial thrombolytics and anticoagulants. In this article, we review acute renal infarction pathogenesis with a focus on AF as an important etiology. World J Nephrol Urol. 2016;5(1):11-15 doi: http://dx.doi.org/10.14740/wjnu242e