CASE REPORT

Abstract

A62-year-old woman presented to her GP in February 1997 with a 4-month history of exertional dyspnoea and ankle oedema. She was referred to a cardiologist for further investigation. She had no other symptoms of note, was a lifelong non-smoker and had no significant family history. Examination revealed mild ankle oedema only. An electrocardiogram at rest showed left bundle–branch block and on exercise testing she developed dyspnoea at an early stage. Coronary angiography revealed minor irregularities in the left coronary artery, while the right was reported as normal and dominant. The left ventricle was dilated with impaired wall movement but no valvular abnormalities. Over the next few months her symptoms failed to improve despite diuretic therapy. She was reviewed by her GP in June 1997, at which time abdominal examination revealed a large right-sided mass. Computed tomography showed a large renal tumour replacing most of the right kidney, while magnetic resonance imaging demonstrated a large enhancing mass, with no involvement of lymph nodes or extrarenal veins, and no metastases (Figures 1 and 2). At preoperative assessment the patient had sinus tachycardia (140 beats per minute) with a blood pressure of 130/85 mmHg. Her jugular venous pressure was elevated 3 cm and a systolic flow murmur with basal pulmonary crepitations were noted. No bruit was audible over the large abdominal mass. Cardiomegaly was present on chest radiograph. She proceeded to a right radical nephrectomy and her postoperative course was uneventful. The patient was last reviewed 18 months after her operation. She was well with almost complete resolution of her symptoms and signs, including a decrease in cardiac size on chest radiography. She was no longer requiring diuretics, and was free of tumour recurrence. An echocardiogram showed residual left ventricular dilatation and an ejection fraction of 22%.