An Unusual Case of Hematuria

Abstract

A 66-year-old woman presented with acute onset of painless gross hematuria and generalized fatigue of 10 days’ duration. The patient was asymptomatic until she started to notice blood in her urine, not associated with dysuria or dribbling. Shortly afterward, she developed oliguria, and swelling of both legs, associated with mild exertional dyspnea, diffuse body aches, and fatigue without subjective fevers or chills. She had no oral or nasal ulcers, alopecia, photosensitivity, joint pain, joint swelling or redness, or symptoms of Raynaud’s phenomenon. She had mild exertional shortness of breath, but without chest pain or cough. She denied abdominal pain or any change in her bowel habits. Beside the gross hematuria, she denied any other urinary symptom. She denied weight loss, recent travels, or sick contacts. On evaluation in the emergency department, she was afebrile but hypertensive (blood pressure 188/98 mm Hg), which was a new symptom for her. She had periorbital edema as well as bilateral lower extremity pitting edema to the knees. Laboratory evaluation in the emergency room showed normocytic anemia, blood urea nitrogen of 44 mg/dl (normal range 7–18), and a creatinine level of 3.8 mg/dl (normal range 0.6–1.2). Her estimated creatinine clearance was 11.9 ml/minute/1.73 m (normal range 80–125) with a fractional excretion of sodium of 2.5%. Her creatinine was checked 3 weeks prior to admission during a routine checkup and found to be elevated at 1.4 mg/dl. She had a potassium level of 5.5 mEq/liter (normal range 3.5–5.1), a phosphorus level of 6.1 mg/dl (normal range 2.8–4.1), and a total calcium level of 8.2 mg/dl (normal range 8.4–10.2). Her urine analysis at presentation revealed 3 proteins, 3 blood, gross red blood cells (RBCs), 1–3 white blood cells, and trace leukocyte esterase. A chest radiograph performed on admission showed cardiomegaly with mild congestion. Kidney ultrasound did not show any hydronephrosis, kidney mass, or evidence of nephrolithiasis. She was admitted to the general medical floor with a diagnosis of acute kidney injury and nephrotic syndrome.