報告者： fellow 1 陳筱惠

Name: 陳 O 綢Sex: femaleAge: 52-year-oldChart number: 21512475Date of admission: 2012/01/07

Intermittent gross hematuria about half year

Underlying diseases: hypertension, diabetes mellitus, and chronic kidney disease (stage 5)

Intermittent gross hematuria for about half year

Associated S/S: right flank pain and urinary frequency No fever, weight loss, abdominal pain, general

weakness, poor appetite, nause/vomiting, or dysuria

LMD: treated as UTI initially, then MRI there with liver and right renal tumor

Hypertension, diabetes mellitus, and chronic kidney disease (stage 5)

Urolithiasis: deniedOther significant systemic

diseases: deniedCurrent medicine: anti-HTN

medication and OHA from LMD

Allergy: no known allergyAlcohol: denied; betel-nut: denied;

cigarette: deniedOver-the-counter medication or

chinese herb: nil

No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Vital signs: blood pressure: 181/87mmHg; temperature: 36.8‘C; pulse rate: 96/min; respiratory rate: 20/min

General appearance: acute ill looking Eye: conjunctiva: pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein

engorgement Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or

S4, no murmurs Abdomen: soft, flat, no tenderness, muscle guarding, or

rebounding liver/spleen: impalpable bowel sound: normoactive Back: mild right flank knocking discomforts Extremities: no lower limb pitting edema Skin: intact, no rash

WBC 6.2x1000/ul

Hgb 8.3 g/dl

Hct 24.5 %

MCV 90.7 fl

PLT 241 x1000/uL

Segment 59 %

Creatinine 5.11 mg/dl

GPT 19 IU/L

K 4.1 mEq/L

Sugar 162 mg/dl

Color Dark yellow

Turbidity Cloudy

SP. Gravity 1.014

PH 6.0

Leukocyte 1+

Nitrite -

Protein 2+

Glucose Trace

Ketone -

Urobilinogen 0.1

Bilirulin -

Blood 3+

bacteria +

RBC >500/uL

WBC 63/uL

Epithelial cell 17/uL

01/04 urine culture: mixed flora

T1

T2

T1

T2

Left kidney Length: 9.4 cm Right kidney Length: 8.8 cm

1 mixed-echoic mass lesion in the low pole (3.7 cm )

Irregular contour, increased cortical echogenicity with reduced thickness; no pelvocalyceal system dilatation; no obvious renal stone or cyst

1/9 urine cytology: SUGGESTIVE OF MALIGNANCY

1/12 CT guided kidney biopsy: CARCINOMA BOTH RCC AND TCC ARE POSSIBLE.

1/13 echo guided liver biopsy: POORLY DIFFERENTIATED CARCINOMA, METASTATIC THE CD10 NEGATIVITY FAVOR IT TO BE OF

UROTHELIAL ORIGIN.

Origin Embryologically

Clinical Immunohistochemically

RCC

the parenchyma of the kidney, proximal convoluted tubules mesodermal

metanephros

• Clinical triad: <10% patient

• Paraneoplastic syndrome

Positive:vimentin, bcl-2, CD10, LMWCK, CK7Negative: CK8, CK19, CK20, HMWCK

TCC

urothelia of the renal pelvis and calices

• Hematuria: 75% patient

• Urine cytology: +

Positive:LMWCK, CK7, CK8, CK19, CK20, HMWCKNegative: vimentin, CD10

Name: 徐 O 妹Sex: femaleAge: 71-year-oldChart number: 21511980 Date of admission: 2011/12/29

Bilateral flank pain for several months

Underlying diseases: hypertension, urolithiasis history

Bilateral flank pain for several months

Associated S/S: fever, nausea/vomiting No abdomial pain, dysuria, or hematuria

LMD: poor renal function (BUN: 80, crea: 9.8) and bilateral renal stone

Underlying diseases: hypertensionOther significant systemic

diseases: deniedL‘t renal stone s/p PCWL and R‘t

ureteral stone with hydronephrosis s/p DJ

Current medicine: anti-HTN medication from LMD

Allergy: no known allergyAlcohol: denied; betel-nut: denied;

cigarette: deniedOver-the-counter medication or

chinese herb: nil

No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Vital signs: blood pressure: 246/136mmHg; temperature: 36‘C; pulse rate: 88/min; respiratory rate: 17/min

General appearance: acute ill looking Eye: conjunctiva: mild pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein

engorgement Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or

S4, no murmurs Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive Back: bilateral flank knocking pain Extremities: no lower limb pitting edema Skin: intact, no rash

WBC 8.0x1000/ul

Hgb 10.9 g/dl

Hct 34.8 %

MCV 79.6 fl

PLT 283x1000/uL

Segment 73.4 %

BUN 70.4 mg/dl

Creatinine 10.23 mg/dl

GPT 9 IU/L

NA 138 mEq/L

K 5.3 mEq/L

Sugar 107 mg/dl

PH 7.247

PCO2 33.1 mmHg

PO2 65.9 mmHg

HCO3 14.1 mm/L

SaO2 90.1 %

Color Yellow

Turbidity Turbid

SP. Gravity 1.007

PH 6.0

Leukocyte 3+

Nitrite +

Protein 1+

Glucose -

Ketone -

Urobilinogen 0.1

Bilirulin -

Blood 2+

bacteria +

RBC 5/uL

WBC 312/uL

Epithelial cell 1/uL

12/28 urine culture: E.coli

A outpouching mass adjacent right posteior kidney with calcification and suspicious necrotic center, surrounding with few lymph nodes and stranding fat-plane, RCC should be considered first.

Left ureteral stone (0.9 cm in diameter) and left calyceal stones

Bilateral hydronephrosis and bilateral hydroureter with thin renal cortex, suggesting chronic renal impairment. R/O right UP or upper ureter obstruction

Left Kidney Length: 11.4 cm Hyperechoic lesions with acoustic shadow

Right Kidney Length: 10.7 cm 1 heterogenous mass-like lesion (9.0x5.9cm) with 2

central calficication spot, protruding from upper pole with extention to right suprarenal fossa

The both kidneys are normal in size and contour. The cortical echogenicity and thickness are normal.

No evidence of renal stone or cyst Mild-to-moderate pelvocalyceal dilatation over

the central sinus area of bilateral kidney, with proximal ureteral dilatation

2011/12/28 OP: bilateral DOUBLE-J URETERAL STENT INSERTION

2012/01/05 CT guided kidney biopsy: RENAL CELL CARCINOMA

Name: 陳 O 慧Sex: femaleAge: 27-year-oldChart number: 20990430Date of admission: 2012/01/29

Diffuse abdomninal dull pain with fever for 1 week

Ectopic pregnancy history post operation in 2006; Ketamine drug abuser??

Diffuse abdomninal dull pain for 1 week

Associated S/S: fever, dyspnea, dysuria, decreased urine output, nausea sensation

Ectopic pregnancy history post operation in 2006

Significant systemic diseases, like hypertension, diabetes mellitus: denied

Current medicine: nil

Allergy: no known allergyAlcohol: social drainking; betel-nut:

denied; cigarette: 1ppd/day for 8 years

Over-the-counter medication or chinese herb: nil

Ketamine drug abuser??

No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Vital signs: blood pressure: 142/88mmHg; temperature: 35.4‘C; pulse rate: 112/min; respiratory rate: 25/min

General apperance: acute ill looking Eye: conjunctiva: mild pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein

engorgement Chest: symmetric expansion

breathing sound: bilateral clear heart sound: regular heart beats, no S3 or

S4, no murmurs Abdomen: soft, flat, no abdominal tenderness, muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive Back: bilateral flank knocking pain Extremities: no lower limb pitting edema Skin: intact, no rash

WBC 18.4x1000/ul

Hgb 6.4 g/dl

Hct 22.5 %

MCV 71.2 fl

PLT 600x1000/uL

Segment 88.5 %

Sugar 144 mg/dl

Creatinine 7.61 mg/dl

GPT 57 IU/L

Lipase 117 IU/L

ALK-P 984 IU/L

Bil (T) 0.4 mg/dl

NA 126 mEq/L

K 7.8 mEq/L

CRP 208.02 mg/L

PH 7.16

PCO2 22.6 mmHg

PO2 32.1 mmHg

HCO3 7.9 mm/L

SaO2 48 %

Color Yellow

Turbidity Turbid

SP. Gravity 1.013

PH 8.0

Leukocyte 3+

Nitrite -

Protein 3+

Glucose -

Ketone -

Urobilinogen 0.1

Bilirulin -

Blood 3+

bacteria +

RBC 120/uL

WBC >500/uL

Epithelial cell 12/uL

01/28 urine culture: E.coli

Markedly atrophy of right kidney Left perinephric fat strandings; enlarged left

kidney with heterogeneous parenchymal enhancement; dilated left pelvocalyceal system with strong wall enhancement

Long segmental left ureteral wall thickening with strictures

LNs enlargement at left renal hilum and left para-aortic space

No intraperitoneal free fluid, no extraluminal free air.

Elongated gallbladder without cholecystitis; The liver, spleen, pancreas are unremarkable.

Left Kidney Length: 13.8 cm Increased echogenicity with prominent

and heterogenous papillae suspect acute papillary necrosis

Right Kidney Length: 0 cm No evidence of renal stone or mass

Kidney: Heroin and cocaine focal segmental

glomerulosclerosis (FSGS) The exact cause of this condition remains in

dispute.▪ Immune-mediated??

Heroin: interstitial nephritis with fibrosis, lymphocytic and plasma cell infiltrates

Cocaine: more renovascular disease and interstitial nephritis than controls

The histopathology of drugs of abuseHistopathology 2011, 59, 579–593

Urinary tract: Ketamine V.S. cystitis

▪ The destruction of the lower urinary tract by ketamine abuse: a new syndrome? BJU Int. 2008; 102; 1616–1622.

▪ 59 patients with lower urinary tract symptoms▪ 12 patients had bladder biopsies.

cystitis with denudation of the urothelium, granulation tissue in the lamina propria and an infiltrate predominantly of lymphocytes with variable eosinophils