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X-ray Conference

X-ray Conference. Presented by F1 林立原 Commented by Dr. 王俐人 2011/11/09. Case 1: 21082252 Case 2 : 21505562. Case 1: 21082252. General Data. Age: 44-year-old Gender: male Ethnic: Taiwanese Marital status: Married Occupation: 電機工程 技術員 Admission date: 2011/09/05. Chief Complaint.

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X-ray Conference

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  1. X-ray Conference Presented by F1 林立原 Commented by Dr.王俐人 2011/11/09

  2. Case 1: 21082252Case 2: 21505562

  3. Case 1: 21082252

  4. General Data • Age: 44-year-old • Gender: male • Ethnic: Taiwanese • Marital status: Married • Occupation:電機工程技術員 • Admission date: 2011/09/05

  5. Chief Complaint • Dizziness for 1 day

  6. Present Illness • This 44-year-old male has hypertension, and chronic kidney disease for 1 year, which was noticed by a health exam. • He presents with dizziness for one day, along with nausea and vomiting. • No spinning sensation, tinnitus, blurred vision, palpitation, chest tightness/pain, shortness of breath, fever, URI symptoms

  7. Present Illness • At ER, high BP was noticed.(234/135 mmHg) Under the impression of hypertension crisis, he was admitted.

  8. Past History • Chronic hepatitis B • Hypertension known for one year, under Bisoprolol5mg QD, Minoxidil5mg QD, Lercanidipine10mg QD, Doxazosin4mg QD, Indapamide1.5mg QD • Hyperlipidemia

  9. Personal History • No known allergy to food or drugs • Smoking: 1 pack per day for 20 years • Denies alcoholism, or betel nuts chewing.

  10. Physical Examination • T 35.5℃ P: 79/min, R: 16/min, BP: 234/135mmHg • Height: 164cm, weight: 52.3kg, BMI:19.4 • Consciousness: alert and oriented • HEENT: pink conjunctiva, no thyroid goiter • Chest: smooth respiration, bilateral clear breathing sounds. • Heart: regular heart beats, no murmurs. • Abdomen: soft, flat, normal bowel sounds • Extremity: freely movable, no pitting edema.

  11. Laboratory Findings

  12. Laboratory Findings

  13. Laboratory Findings

  14. CXR

  15. Impressions • Suspect secondary hypertension, poor control with hypertensive emergency • Chronic kidney disease, stage 4, eGFR: 16.7ml/min/1.73m2

  16. Hospitalization course Cr: 4.18 (9/04) Cr: 11.0 (9/08) Cr: 16.8 (9/13) 9/08 Kidney echo 9/15 Start HD 9/19 CTA of Abdomen 9/26 operation

  17. 2011/09/08 Kidney Echo

  18. 2011/09/08 Kidney Echo • Left Kidney Length: 9.0 cm • Right Kidney Length: 9.5 cm • The left kidney is borderline small in size and the right kidney is normal in size, both with mildly irregular contour. The cortical echogenicity is increased with adequate thickness. The pelvocalyceal systems are not dilated. No obvious evidence of renal stone, mass or cyst is noted. • No adrenal gland mass is noted.

  19. 2010/09/19 Abdominal CT

  20. 2010/09/19 Abdominal CT

  21. 2010/09/19 Abdominal CT

  22. 2010/09/19 Abdominal CT • Multiple outpouch of abdominal aorta at the level of SMA root to the aortic bifurcation. Some infiltrative soft tissue in the peri-aortic region (Se5 Im29, 34~39). Mycotic aortic aneurysms is suspected. Mural thrombus in some of the aneurysm sac is seen. • No definite supra-renal mass is seen. • Large amount of ascites in the peritoneal cavity, cause unknown. • Mild splenomegaly. Gastric varices, indicating portal hypertension. • Mild cardiomegaly. Bil. pleural effusion, nature unknown. Minimal atelectasis of BLLs. • Impression: • 1. Multiple abdominal aortic aneurysm with peri-aortic soft tissue, R/O mycoticaneurysm. • 2. No evidence of pheochromocytoma in the bil. adrenal gland or retroperitoneum. • 3. Ascites and pleural effusion, nature unknown.

  23. 09/26 OP and Angiography • 1. The aortography revealed califloweraneurymal dilation of aorta with multiple separation involving SMA, bilateral renal arteries, and downward to aortic bifurcation. Pseudoaneurysms or mycotic aneurysm was considered. • 2. After successful canulation of guided wire, chimney for the SMA with viabahn 8mm/10 cm followed by implantation of left side manibody Gore Excluder PXT 261418 plus iliac PXC 121000, right side iliac PXC 141400 plus PXL 161207 landed on bilateral CIAs. • Impression: Abdominal aortic pseudoaneurysms or mycotic aneurysm S/P successful EVAR.

  24. Diagnosis • Multiple abdominal aortic aneurysm • Acute kidney injury, RIFLE-F, in uremic stage, on maintenance hemodialysis since 09/15 • Secondary hypertension, due to abdominal aortic aneurysm with involvement of bilateral renal artery

  25. Discussion

  26. Case 2: 21505562

  27. General Data • Age: 73-year-old • Gender: male • Ethnic: Taiwanese • Marital status: married • Occupation: farmer

  28. Chief Complaint • Right adrenal mass noticed in 新竹馬偕醫院

  29. Present Illness • This 73 year-old male has hypertension and arrythmia with OPD follow-upin 為恭 hospital. He was sent to 為恭 hospital because of sudden onset of conscious loss on 08/31, when he was reading. Hypokalemia and UTI were impressed, but he did not regain conscious.

  30. Present illness • Thus he was transferred to 新竹馬偕, where right adrenal mass with hyperaldosteronism was noticed (renin:0.34ng/ml/hr, aldosterone 532.40pg/ml); and he was transferred to CGMH for surgical intervention.

  31. Past History • Hypertension • Sick sinus syndrome with high grade AV block post permanent pacemaker implantation on 2011.9.10 • Paroxysmal atrial fibrillation • Benign prostatic hypertrophy post operation

  32. Personal History • No known allergy to foods or drugs • Smoking: 1 pack per day for more than 20 years • Alcoholism: denies • Betel nut chewing: denies

  33. Physical Examination • BT 36℃ PR: 81/min, RR: 20/min, BP:133/92mmHg • Height: 170cm, weight: 73kg, BMI:25.2 • Consciousness: alertand oriented • HEENT: pink conjunctiva, anicteric sclera • Chest: symmetrical expansion, bilateral clear breathing sounds. • Heart: regular heart beats • Abdomen: soft , normoactive bowel sounds • Extremity: freely movable, no pitting edema

  34. Laboratory Findings

  35. Laboratory Findings

  36. Laboratory Findings

  37. Laboratory Findings

  38. CXR

  39. 2011/09/26 Kidney echo

  40. 2011/09/26 Kidney Echo • Left kidney length: 10.9cm • Right kidney length: 11.3 cm • The both kidneys are normal in size with normal outline. The cortical echogenicity is increased with adequate thickness. • There is an iso to hypo-echoic heterogenous lesion (5.2x3.6cm) in the right supra-renal region.

  41. 2011/09/13 Abdominal CT

  42. Operation and Pathology • 10/04: Right adrenectomy with retroperitoneal tumor dissection • Pathology: Highly suggestive of cortical carcinoma

  43. Diagnosis • Right adrenal cortical carcinoma, complicated with hypokalemia and secondary hypertension

  44. Discussion

  45. Adrenal mass • The maximum diameter of the adrenal mass is predictive of malignancy. Most adrenal adenomas are < 4cm in diameter. • The lipid-rich nature of cortical adenomas is helpful in distinguishing this benign tumor from carcinoma • CT, MRI, PET

  46. Adrenocortical carcinomas • Inhomogeneity, irregular borders, calcifications, invasion of surrounding structures or lymph node enlargement; • <50 percent contrast washout at 10 minutes • most adrenocortical carcinomas are > 4cm at diagnosis

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