Abstract
BackgroundXanthogranulomatous pyelonephritis is a rare and serious manifestation of chronic kidney inflammation that can be life-threatening if not recognized and treated appropriately, often with antibiotics and surgery. Affected patients are most commonly females in their fifth or sixth decade of life with a background of obstructive uropathy, nephrolithiasis, or recurrent urinary tract infections who present with vague nonspecific symptoms.Case presentationA 43-year-old woman of Russian ethnicity with a history of nephrolithiasis presented to our emergency department with new left-sided pleuritic chest pain amid a 6-week history of constitutional symptoms including fevers, night sweats, and 7 kg of weight loss. Workup for acute coronary syndrome and pulmonary embolism in our emergency department was negative. Given that she was clinically unwell, she was admitted to internal medicine to expedite workup for the cause of her symptoms. A broad differential diagnosis for various infectious, inflammatory/autoimmune, and neoplastic processes was considered. Based on classic radiographic and histopathologic findings, she was ultimately diagnosed with xanthogranulomatous pyelonephritis of her left kidney, which was a direct consequence of chronic inflammation. This inflammation exhibited spread to local tissues and across her left hemidiaphragm, resulting in a unilateral pleural effusion which explained her chest discomfort. She was treated with antibiotics administered intravenously and urgent total nephrectomy with a good functional outcome.ConclusionsOur case illustrates an uncommon but clinically important do-not-miss diagnosis that underlies a common clinical presentation of pleuritic chest pain. The case underscores the importance of maintaining a broad differential diagnosis and organized approach when treating patients with undifferentiated clinical presentations.
Highlights
Xanthogranulomatous pyelonephritis is a rare and serious manifestation of chronic kidney inflammation that can be life-threatening if not recognized and treated appropriately, often with antibiotics and surgery
The case underscores the importance of maintaining a broad differential diagnosis and organized approach when treating patients with undifferentiated clinical presentations
The prototypical patient affected by this condition is a female in her fifth or sixth decade of life with a background of obstructive uropathy presenting with nonspecific constitutional symptoms [1]
Summary
To the best of our knowledge, this is the first reported case of a patient with XGP presenting with pleuritic chest pain as a chief symptom Her pain was explained by local spread to and inflammatory involvement of her left hemidiaphragm, an atypical presentation of this disease. This case reaffirms the need to consider a broad differential diagnosis in the medically undifferentiated patient; in patients with a history of lower urinary tract pathology presenting with abdominal, flank, or even chest pain amid constitutional symptoms, it may be reasonable to consider retroperitoneal infectious/inflammatory processes such as XGP in the differential diagnosis and, in the correct clinical context, adopt a low threshold to order imaging studies of the abdomen/pelvis and obtain early urological consultation
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