9/8/17 Intern Morning Report – Hematuria, Urinary clots, Hypercalcemia, Renal Cell Carcinoma

CC: Bloody urine

ID: This is a 56 yo M with history of hypertension and prior episodes of gross hematuria that presents with bloody urine for three days. In addition he has noticed clots in his urine, flank pain, constipation as well as decrease urine output. However, the patient denies dysuria, fevers, or weight loss. His exam demonstrates slight suprapubic pain but no other significant findings. Organomegaly was not appreciated but it was a difficult exam due to body habitus. Labs were significant for BUN/Cr: 26/1.65, Calcium 11, UA: large blood, >50 RBC/HPF with 100 protein and no RBC casts, and PTHrP 41. Given hypercalcemia secondary to elevated PTHrP and non-glomerular bleeding, suspicion for renal cell carcinoma is high. A CT urogram was pursued demonstrating necrotic right renal mass, involving the right renal vein and indeterminate involvement of the inferior vena cava.


Teaching Points

  1. Differentiate between glomerular and non-glomerular bleeding in hematuria cases

Glomerular Bleeding Findings

Non-Glomerular Bleeding Findings

·               Urinary acanthocytes

·               Urinary RBC casts

·               Proteinuria

·               Decrease renal function

·               Systemic symptoms

 

·               Urinary clots

·               Isomorphic RBCs

2. Perform a basic work up for Hypercalcemia:

10/28/16 Intern Morning Report – Genitourinary Tuberculosis

CC: 1 week of bloody, purulent urethral meatus discharge

ID: 32 yo Filipino male with history of prior sexual assault with subsequent recurrent UTIs, and newly diagnosed urethral stricture s/p suprapubic catheter placement presents with 1 week of bloody, purulent discharge from his urethral meatus. On exam, he was noted to have milky, bloody discharge from his meatus and fluctuant paratesticular masses in bilateral scrotum and base of the penis. Scrotal ultrasound revealed abscesses within bilateral scrotum and penis. He was taken to the OR for surgical exploration and abscess drainage. Pathology specimen was remarkable for caseating granulomatous inflammation with positive AFB stains in the peritesticular abscess fluid. Patient was ultimately diagnosed with genitourinary tuberculosis.

Genitourinary TB
Left peritesticular sack abscess: Fibrous tissue with caseating granulomatous inflammation.

Pearls from morning report:

  • The differential for sterile pyuria is broad and includes TB, fungal organisms, urinary stone, interstitial cystitis, prostatitis, STIs and PID.
  • When evaluating acute scrotal pain, consider Prehn’s sign. A positive Prehn’s sign (alleviation of pain with scrotal elevation) indicates epididymitis, not testicular torsion.

Random trivia:

LAC+USC is proud to diagnose and treat 1% of all tuberculosis cases nationwide. The earliest evidence of TB in men and animals was discovered in the form of fossils – spinal TB – dating back to 8000 BC.


Want to read more?

Genitourinary TB: historical and basic science review (Central European Journal of Urology)
Sterile Pyuria (New England Journal of Medicine)


References: 

 

Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehensive review. Am Fam Physician. 2005;71(6):1153-62.

Grabe M, Bjerklund-Johansen TE, Botto H, Çek M, Naber KG, Pickard RS, Tenke P, Wagenlehner F, Wullt B. Guidelines on urological infections. European Association of Urology 2016. Accessed October 31, 2016.