Download Case 31-2007 — A 41-Year-Old Man with Abdominal Pain and

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Presentation of Case
A 41-year-old man was admitted to this hospital because of abdominal pain, nausea, and
an elevated serum creatinine level. He had been in good health until 6 days before
admission, when chills and malaise developed. At that time, his body felt warm to the
touch, but the temperature was not measured. He took ibuprofen (at a dose of 400 mg)
orally every 6 hours for three or four doses, with some improvement in his symptoms.
Weakness and nausea developed, and he took one dose of an over-the-counter
medication that included acetaminophen, dextromethorphan, and pseudoephedrine, with
improvement in his symptoms.
Two days after the onset of symptoms, he felt well enough to play golf, but by the 15th
hole, he felt weak and fatigued. After eating, he felt bloated, nauseated, and thirsty. That
evening, he vomited food and bilious fluid. He had difficulty sleeping.
The next day, he felt nauseated and fatigued; these symptoms worsened after eating.
Epigastric and periumbilical pain, which he rated as between 8 and 9 on a scale of 1 to
10 (where 10 is the most severe pain), and persistent hiccupping developed. He passed
loose, light brown stools on several occasions, without blood. Headache and myalgias
developed, and he stopped eating solid foods and drank only a few cups of liquid.
On the fifth day, he saw his primary care physician. On examination, the breath sounds
were normal, bowel sounds were present, and the abdomen was soft with diffuse, mild
tenderness. Trimethobenzamide hydrochloride (100 mg) was administered
intramuscularly, and trimethoprim–sulfamethoxazole combination (one single-strength
tablet twice daily), hyoscyamine (0.125 mg) as needed for abdominal pain, and
prochlorperazine as needed for nausea were prescribed. Increased intake of fluids was
advised, and a follow-up visit was scheduled.
The next day, nausea, anorexia, and abdominal pain persisted, and the urinary output
decreased. The patient went to the emergency room of another hospital. He rated the
abdominal pain as 6 on a scale of 1 to 10. On physical examination, he appeared ill. The
temperature was 36.5°C, the blood pressure was 126/85 mm Hg, and the pulse was 83
beats per minute; the respirations were 12 per minute, and the oxygen saturation was
99% while the patient was breathing ambient air. The oral mucous membranes were dry,
and the abdomen was tender in the lower quadrants; the remainder of the physical
examination was normal. The results of laboratory tests are shown in Table 1 and Table
Results of electrocardiography showed no abnormalities. A bolus of normal saline was
given, followed by a continuous intravenous infusion, and a Foley catheter was inserted.
Ultrasonography of the abdomen revealed that the kidneys were normal in size (right
kidney, 10.5 cm long; left kidney, 10.7 cm), shape, and position. The renal cortexes
were slightly hyperechoic relative to the liver. There was no evidence of urinary
obstruction; a small amount of ascites was noted. Radiographs of the chest and abdomen
showed normal lungs, no free intraperitoneal air, and several gas-filled loops of small
bowel in the left middle portion of the abdomen that were at the top of the normal range
for caliber, a finding consistent with a mild ileus.
Specimens of blood and urine were sent for cultures. Ranitidine (50 mg), ceftriaxone (1
g), and ondansetron (4 mg) were administered intravenously. The patient was
transported by ambulance to this hospital nearly 12 hours after his presentation at the
other hospital. By the time of the transfer, 1200 ml of normal saline had been infused,
and 120 ml of urine had been excreted.
A dental procedure had been performed approximately 10 days before admission, and
the patient had a history of stress-related gastroesophageal reflux disease. He had no
allergies to medications. The patient lived with his family in a Western European
country and worked in finance. He had traveled to New England to visit relatives and
had no other important history with respect to travel, changes in diet, or contact with
sick persons. He was monogamous with his wife. He had visited southeastern
Massachusetts, which is an area where the ixodes tick is endemic, and played golf
weekly, but he had no history of tick bites. He drank two glasses of wine per week; he
had smoked 10 cigarettes per day for 18 years but had stopped 3 years earlier. There was
no history of use of illicit drugs. The family owned a dog, but he had had no recent
contact with it. The patient's mother had died from pancreatic cancer, and his father had
type 2 diabetes mellitus; his siblings and children were in good health.
On examination, the patient was obese, appeared ill, and had hiccups. The temperature
was 36.5°C, the blood pressure was 114/69 mm Hg, and the pulse was 88 beats per
minute; the respirations were 18 per minute, and the oxygen saturation was 97% while
the patient was breathing ambient air. There was no jugular venous distention; the
mucous membranes were slightly dry. The sclera were anicteric. There was a systolic
ejection murmur (1 of 6) at the apex that did not change with movement or handclenching. The abdomen was distended, with increased bowel sounds but no tenderness
or organomegaly. Rectal examination showed no abnormalities; a stool specimen was
trace-positive for occult blood. The remainder of the examination was normal.
Levels of serum complement and immunoglobulins and the results of serum
immunoelectrophoresis were normal; tests for antinuclear antibody and antineutrophil
cytoplasmic antibody were negative. Results of other laboratory tests are shown in
Table 1 and Table 2. A chest radiograph showed mild pleural thickening. A specimen of
blood was sent for culture. When examined by the nephrologist, the urinary sediment
contained many finely granular casts, some cellular casts that were possibly
tubuloepithelial, and red cells. The fractional excretion of sodium was calculated as
3.5%. Examination of the peripheral-blood smear by a hematologist showed no
schistocytes. Methylprednisolone (1 g) was given intravenously.
The next day, repeated examination of the urinary sediment by a nephrologist showed
more casts, including degenerating cellular casts and some pigmented, coarsely granular
casts (Figure 1). The total protein-to-creatinine ratio in a spot urine sample was 2.9. A
diagnostic procedure was performed.
Figure 1. Photomicrograph of Unstained Urinary Sediment from
Another Patient with Acute Tubular Necrosis.
The sediment has a pigmented, coarsely granular cast, which is
characteristic of tubular injury. (Image courtesy of Dr. Garner T.
Haupert, Nephrology Division, Massachusetts General Hospital.)