病例報告 - 腎臟囊腫, 膿瘍或血管肌肉脂肪瘤破裂?

吳奕儒、陳妤甄、吳文正

高雄醫學大學附設中和紀念醫院 泌尿科

A case report: The dilemma of renal mass leision, abcess or Angiomyolipoma(AML) rupture?

Yi-Ru Wu、Yu-Chen Chen、Wen-Jeng WU
Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Abstract:

  A 74-year-old female with underlying disease of Atrial fibrillation under Propranolol control(without anticoagulant used) and denied hypertension or diabetes mellitus who suffered from fever with chillness for 3 days, Associated symptoms included left flank pain, denied any lower urinary tract symptoms, denied  nausea/ vomiting, denied upper reparatory symptoms. Physical Examination showed mild left flank knocking pain and no obvious ecchymosis. Sonography showed bilateral no hydronephrosis but left renal mass was noted. Laboratory data showed hemoglobin=14, mild leukocytosis(10,8500/uL) with CRP(C-reactive protein)(20mg/L) elevation, creatinine level was 0.65mg/dL. Urine routine revealed no pyruria nor microscopic hematuria. Chest X-ray showed no obvious pneumonia patch. Abdominal computed tomography (figure 1.) revealed a hypovascular mass lesion (2.68cm, CT number around 20-50HU) at left kidney with adjacent infiltrations and fluid. Differential diagnosis: renal abscess, angiomyolipoma with rupture/hematoma. Radiologist more favor Angiomyolipoma(AML) rupture and suggested transcatheter arterial embolization.

  Due to stable clinical patterns, we observed and rechecked the hemoglobin on the next day, which showed no obvious decreased level (Hb=14); therefore, AML rupture was not highly preferred.

We then gave the patient with IV form antibiotics. After five days of antibiotic treatment, fever subsided and left flank pain improved more. Infection parameters also showed improvement. Bedside echo also showed relatively decreased size of left renal mass. Therefore, the renal abcess was impressed.

  The distinct impression of renal abscess and Angiomyolipoma(AML) rupture was diagnosed by radiologists and urologists.  It may lead to different treatment programs. In this case, we prefer renal abscess instead of AML rupture.  After antibiotic treatment, patient recovery well.

In conclusion, in the similar case which is difficult to make the differential diagnosis between renal abcess and AML rupture, we should always monitor patients’ clinical pattern and give best treatment strategy to the patient.