Upper tract urothelial cell carcinoma presenting as fever of unknown origin and acid-sterile pyuria

Abstract

Urothelial carcinomas are the fourth most common tumors. They can be divided in carcinomas of the lower urinary tract, if located in the bladder or urethra, or upper urinary tract carcinomas if located in the pyelocaliceal cavities and ureter. Bladder tumors represent the most common malignancy of the urinary tract, and account for the 90–95 % of urothelial carcinomas. On the other hand, upper tract urothelial carcinomas are uncommon, and account only for 5–10 % of urothelial tumors [1, 2]. We report a case of a 63-year-old woman referred to our department in February 2011 for a fever of unknown origin (FUO). She had suffered 30 months prior from mammary ductal carcinoma (staged pT1bN0), treated with quadrantectomy and tamoxifen, switched to exemestane after 2 years (of therapy); moreover, she was affected from HCV-related chronic hepatitis (viraemia: 1.22 9 10 IU/ mL, genotype 1b; naive) discovered in 1997. She complained of fevers up to 39 C mostly ‘‘nocturnal’’ sometimes accompanied by diarrhea, malaise, loss of appetite, weight loss and profuse sweating begun 4 months before. The patient was previously admitted in a different department of internal medicine for the same clinical status. During the hospitalization an abdomen computed tomography (CT scan) was performed that revealed only a reduced enhancement of contrast media in the upper pole of the left kidney. The patient was therefore discharged with a diagnosis of ‘‘fever in remission and renal ischemia’’. 1 month later, the temperature was still elevated, and the patient was admitted to our department. The physical examination revealed an emaciated facies, a body temperature of 37.8 C, a blood pressure of 160/80 mm Hg, and a murmur 2/6 Levine of the mitral valve; the remainder of the physical examination was normal. A complete blood count (CBC) showed a neutrophil leucocytosis (WBC: 11,200/mm, Ne 79.3 %) and a microcytic hypochromic anemia (related to a b-thalassemia trait). Other laboratory tests: GOT, GPT and c-GT were mildly elevated (1.25 ULN), C-reactive protein (CRP) was 1.77 mg/dL (normal value \0.5 mg/dL); electrolytes, erythrocyte sedimentation rate (ESR), blood culture, chest X-ray and urine culture were negative. At echocardiography, performed to exclude a subacute infective endocarditis, the patient presented only a mild mitral regurgitation with left atrial enlargement; there was no sign of valvular vegetations. At urine analysis the patient presented acid-sterile pyuria. Since the most common cause of sterile pyuria is renal tuberculosis, we proceeded with PPD skin test and Koch bacillus research in the urine; both were negative. As the patient was still febrile, an abdomen-CT scan with contrast media infusion was repeated, and revealed again an impairment of perfusion of the left kidney upper pole (reported as renal ischemia), but this time revealed also many lymphoadenopathies near the left renal vein and in the para-aortic region; the biggest one was 1.3 cm in the lumbar para-aortic region. Therefore, we decided to proceed with a total body F-fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET/CT) to better evaluate the abdominal lymphoadenopathies, and to indentify a possible focus responsible of the fever. The only site with high FDG uptake was the lymph node in the lumbar region (max-standardized uptake value 8.7). About 20 days after admission the patient still presented M. Di Capua (&) P. Ierano E. Marrone A. M. Cerbone G. Di Minno Department of Clinical and Experimental Medicine, Regional Reference Centre for Coagulation Disorders, Federico II University of Naples, Via S. Pansini, 5, 80131 Naples, Italy e-mail: mirdica@hotmail.com