Abstract
Retro-aortic left renal vein (RLRV) is an anatomical variation, where the left renal vein (LRV) courses posterior to the aorta and anterior to the vertebrae before it eventually drains into the inferior vena cava (IVC). RLRV is a rare finding, with a prevalence of around 1%-2%, and only a small minority of RLRVs cause symptoms. RLRV symptoms occur secondary to compression of the LRV between the abdominal aorta and vertebrae, otherwise known as posterior nutcracker syndrome (PNCS). The most common symptoms of PNCS are hematuria and flank pain. We present a 17-year-old male, who came in with recurring left flank pain without hematuria, initially thought to be renal colic secondary to nephrolithiasis. On further investigations, an aberrant posterior renal vein was seen on CT suggestive of PNCS. The patient was treated successfully with RLRV vascular stent placement by interventional radiology. This case report adds to the limited number of PNCS cases observed in children and to the even rarer cases of PNCS without hematuria. This case also acts as a reminder for pediatricians to keep a wide scope of differentials in patients presenting with flank pain and provides an outline of both diagnostic and treatment modalities available for these patients.
Highlights
Nutcracker syndrome (NCS) is an uncommon cause of hematuria that can be either microscopic or macroscopic and accompanied by flank pain
Retro-aortic left renal vein (RLRV) are seen as vascular structures that communicate with the inferior vena cava (IVC), but course posteriorly to the aorta
RLRV recognition is important in order to avoid complications in retroperitoneal surgeries as well as complications of Posterior nutcracker syndrome (PNCS), which include but are not limited to hematuria, varicocele, congested kidney, renal infarcts, renal vein thrombosis, ureteropelvic junction obstruction, bacterial localization, and abscess formation [2, 5]
Summary
Nutcracker syndrome (NCS) is an uncommon cause of hematuria that can be either microscopic or macroscopic and accompanied by flank pain. There are two different forms of NCS, anterior and posterior, which both produce similar symptomology, secondary to impaired outflow of the left renal vein (LRV) into the inferior vena cava (IVC). Posterior nutcracker syndrome (PNCS) is when the LRV follows a retro-aortic course and is compressed between the aorta and vertebral bodies. NCS can present as pelvic congestion syndrome (dysmenorrhea, dyspareunia, lower abdominal pain, and pelvic varices). A 17-year-old male presented to the pediatrician with complaints of intermittent flank pain that began eight months prior. How to cite this article Almuqamam M, Ebrahim M, Nassar G, et al (August 16, 2021) Atypical Posterior Nutcracker Syndrome in a 17-Year-Old Male Without Hematuria. Complete metabolic panel Sodium Potassium Chloride HCO3 Urea nitrogen Creatinine Calcium Glucose (random) Total protein Albumin Alkaline phosphatase Aspartate amino transferase Alanine amino transferase Total bilirubin
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