25-Year-Old Man With Flank Pain, Hematuria, and Proteinuria

Abstract

© 2009 Mayo Foundation for Medical Education and Research A 25-year-old nonsmoking male tire technician presented to the emergency department with a 3-week history of macroscopic hematuria and flank pain. He had previously been feeling well and was taking no regular medications; however, he had seen his primary care physician 10 days previously for left flank pain and was empirically treated for pyelonephritis with oral ciprofloxacin. On presentation, the patient was not passing clots through the urethra, denied recent trauma, and rated his flank pain as 6 on a severity scale of 10, described as constant, bilateral, nonradiating, and pleuritic with no relieving factors. He had no nausea, vomiting, diarrhea, fevers, chills, or rigors. He denied recent travel, animal contacts, occupational exposures, use of over-the-counter medications, or illegal drug use. On examination, the patient appeared clinically well without evidence of distress, pallor, or jaundice. His temperature was 36.8 C, blood pressure was 118/72 mm Hg, pulse rate was 74/min, and oxygen saturation was 95% while breathing room air. Findings on cardiovascular and respiratory examinations were noncontributory. The abdomen was soft, nondistended, and nontender without masses or organomegaly. No costovertebral angle tenderness, suprapubic tenderness, or renal bruits were appreciated. There was no evidence of rash or musculoskeletal abnormality. Laboratory tests yielded the following results (reference ranges provided parenthetically): a normal white blood cell count with no evidence of peripheral eosinophilia; creatinine, 1.5 mg/dL (0.9-1.4 mg/dL); C-reactive protein, 99.2 mg/L ( 8.0 mg/L); and erythrocyte sedimentation rate, 111 mm/h (0-22 mm/h). The estimated glomerular filtration rate (eGFR) was 57 mL/min per 1.73m2 and the international normalized ratio was 1.0. Urinalysis by dipstick showed trace ketones, protein 3+, bilirubin 1+, and occult blood 3+. Initial urinalysis showed reddish urine, a protein concentration of 3100 mg/dL, and a large amount of hemoglobin. Microscopic examination showed more than 100 red blood cells per high power field, with more than 25% dysmorphic red blood cells and no evidence of urinary eosinophils. Chest radiography showed mild bilateral pleural effusions and atelectasis at the left base behind the heart. Computed tomography (CT) of the abdomen and pelvis was performed according to the renal stone protocol; findings were negative for kidney stones.