Costovertebral Angle Research Articles

BILATERAL EMPHYSEMATOUS PYELONEPHRITIS AND CYSTITIS IN AN ESRD PATIENT PRESENTING WITH SEPTIC SHOCK

"BILATERAL EMPHYSEMATOUS PYELONEPHRITIS AND CYSTITIS IN AN ESRD PATIENT PRESENTING WITH SEPTIC SHOCK." Acta Clinica Belgica, 64(2), pp. 160–161Keywords: emphysematous pyelonephritisend-stage renal diseaseseptic shock

Migration of an Ingested Foreign Body into the Right External Iliac Vein

Migration of an Ingested Foreign Body into the Right External Iliac Vein

Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment

The epidemiology of acute pyelonephritis (APN) has changed with time. Therefore we investigated the current clinical characteristics of APN and the significance of proper surgical management for treatment of 1,026 APN patients in South Korea for the past 5 yr. The male-to-female ratio was about 1:8. The peak ages of female patients were 20s (21.3%) and over 60s (23.7%), while that of male was over 60s (38.1%). The occurrence of sepsis was 10.1%. Complicated APN patients were 35.4%. Ninety-four patients (9.2%) needed urological procedures. The duration of the flank pain and of the costovertebral angle tenderness in complicated APN patients was statistically significantly longer than that with simple APN patients (4.3 vs. 3.4 days, 4.4 vs. 4.0 days). If flank pain and costovertebral angle tenderness sustain over 4 days, proper radiologic studies should be performed immediately with the consideration of surgical procedure. Also the resistance to antibiotics was increasing. As the sensitivities to ampicillin (27.2%) and trimethoprim/sulfamethoxazole (44.7%) of Escherichia coli and Klebsiella pneumoniae were very low, it is necessary to take the careful choice of antibiotics into consideration.

Delineation of Inferior Vena Caval Anatomy With 3-Dimensional Computerized Tomography Reconstruction

A55-year-old female presented with a history of intermittent, painful gross hematuria. On examination she was afebrile with stable vital signs and right costovertebral angle tenderness with deep palpation. Hemoglobin, blood differential, blood chemistry studies and urinalysis were unremarkable. Multiphasic helical computerized tomography demonstrated an enhancing 3 5 cm right lower pole mass suspicious for malignancy. Post-processing 3-dimensional reconstructions of the arterial phase computerized tomogram displayed aberrant vena caval anatomy with a left inferior vena cava (IVC) (see figure). Preoperative review of the abdominal venous anatomy enabled an uncomplicated laparoscopic right radical nephrectomy to be performed. Final pathological diagnosis was stage 1b, Fuhrman grade 3, clear cell renal cell carcinoma. Embryologically the abdominal venous drainage system develops from the posterior cardinal, subcardinal and supracardinal veins. 1 These systems, formed by 8 weeks of gestation, communicate with each other, anastomose, and eventually degenerate to leave a right IVC, a short right renal vein and a single ventral left renal vein among other tributaries. The IVC develops from the right subcardinal vein above the level of the renal veins and the vena cava develops from the right supracardinal vein below the renal veins. Anomalies occur with the persistence of additional or other embryonic segments. Persistence of the left supracardinal vein with regression of the right vein results in a left IVC (see figure). Left IVCs cross over the aorta (part B of figure, arrow) and mirror normal vena caval anatomy with the left adrenal and gonadal veins emptying directly into the IVC, while the right adrenal and gonadal veins empty into the right renal vein (part A of figure, arrow). 1 Below the level of the renal veins the aberrant IVC is to the left of the aorta (part C of figure, arrow). Persistence of both supracardinal veins results in a double IVC and can lead to symptoms including renal obstruction/ stones, lumbar/flank pain, hypertension, venous stasis or varicocele. Anomalies of the subcardinal vein can result in interruption of the IVC with azygous/hemiazygous continuation. Persistence of the posterior cardinal veins results in retrocaval/ circumcaval ureters. Although some patients with anomalous abdominal venous drainage may present with symptoms, many are asymptomatic and the aberrant anatomy is discovered incidentally on radiographic evaluation or surgical exploration.

Nephropathia epidemica als Folge einer Puumala-Virus-Infektion bei einer schwangeren Patientin

A 29-year-old woman in the early stage of pregnancy ( approximately 6 (th) week) presented in our hospital with influenza-like symptoms of fever, headache, aching limbs and tenderness over the costovertebral angle. Acute oliguric renal failure occurred within a few days. Ultrasonography revealed symmetrically enlarged kidneys with a small amount of perirenal fluids. The blood count showed thrombocytopenia, and viral serology verified a recent infection with Puumala virus (species of Hantavirus). Epidemic nephropathy was diagnosed. The patient underwent one session of hemodialysis and soon recovered without any residual renal damage. The pregnancy continued without any further complications. There are only few reports on infections with Puumala virus during pregnancy are. None of theses described any fetal abnormalities causes by the maternal infection, as in our patient. Hantavirus infections should be considered in differential diagnosis of acute renal failure in endemic regions.

Index of Suspicion

Index of Suspicion

Contemporary Management of Uncomplicated Urinary Tract Infections

Uncomplicated urinary tract infections (uUTIs) are common in adult women across the entire age spectrum, with mean annual incidences of approximately 15% and 10% in those aged 15-39 and 40-79 years, respectively. By definition, UTIs in males or pregnant females and those associated with risk factors known to increase the risk of infection or treatment failure (e.g. acquisition in a hospital setting, presence of an indwelling urinary catheter, urinary tract instrumentation/interventions, diabetes mellitus or immunosuppression) are not considered herein. The majority of uUTIs are caused by Escherichia coli (70-95%), with Proteus mirabilis, Klebsiella spp. and Staphylococcus saprophyticus accounting for 1-2%, 1-2% and 5-10% of infections, respectively. If clinical signs and symptoms consistent with uUTI are present (e.g. dysuria, frequency, back pain or costovertebral angle tenderness) and there is no vaginal discharge or irritation present, the likelihood of uUTI is >90-95%. Laboratory testing (i.e. urinary nitrites, leukocyte esterase, culture) is not necessary in this circumstance and empirical treatment can be initiated. The ever-increasing incidence of antimicrobial resistance of the common uropathogens in uUTI has been and is a continuing focus of intensive study. Resistance to cotrimoxazole (trimethoprim/sulfamethoxazole) has made the empirical use of this drug problematic in many geographical areas. If local uropathogen resistance rates to cotrimoxazole exceed 10-25%, empirical cotrimoxazole therapy should not be utilized (fluoroquinolones become the new first-line agents). In a few countries, uropathogen resistance rates to the fluoroquinolones now exceed 10-25%, rendering empirical use of fluoroquinolones problematic. With the exception of fosfomycin (a second-line therapy), single-dose therapy is not recommended because of suboptimal cure rates and high relapse rates. Cotrimoxazole and the fluoroquinolones can be administered in 3-day regimens. Nitrofurantoin, a second-line therapy, should be given for 7 days. beta-Lactams are not recommended because of suboptimal clinical and bacteriological results compared with those of non-beta-lactams. If a beta-lactam is chosen, it should be given for 7 days. Management of uUTIs can frequently be triaged to non-physician healthcare personnel without adverse clinical consequences, resulting in substantial cost savings. It can be anticipated that the optimal approach to the management of uUTIs will change substantially in the future as a consequence of antimicrobial resistance.

Sudden loss of consciousness and right flank pain associated with renal infarction.

While at home, a 77-year-old woman with atrial fibrillation (Af), coronary artery disease, hypertension and a 10-year history of hyperlipidaemia experienced a loss of consciousness combined with sudden onset of right flank pain and fell on the ground. She was brought to our hospital where brain computerized tomography (CT) revealed an acute infarction over the left middle cerebral artery and posterior cerebral artery. Electrocardiography showed Af with a ventricular rate of 116 beats per minute. Her blood pressure was 130/70 mmHg, and her heart beat was irregular. She had normal pupil size and light reflex. There was a throbbing pain over her right costo-vertebral angle but no local abdominal tenderness was seen. No bruit was heard. Her white blood cell count was 20420/cumm, haemoglobin 12.5 g/dL and platelets 208 × 103/cumm. Her serum lactate dehydrogenase was 1000 IU/dL, creatinine 2.1 mg/dL, urea nitrogen 24 mg/dL and potassium 3.2 mmol/L. Urine analysis revealed protein 2+, red cell 2–5/ high power field (HPF) and white cell 1–3/ HPF. Markers for anticardiolipin antibody, lupus anticoagulant, anti-thrombin III, and protein C and S were unremarkable. Abdominal contrast with CT revealed a markedly less-enhanced right renal parenchyma (Figure 1). An enhancement of the left kidney was also noted. There were no stones and no perinephric inflammatory stranding. Renal arterial angiography (Figure 2A) revealed total occlusion of the right renal artery and

Results of Multimodal Treatment of Two Patients with Thoracic Primitive Neuroectodermal Tumor. Is Surgery Really Helpful for Survival?

Primitive neuroectodermal tumors (PNET) belong to the group of small round cell tumors and are rarely seen. They are rapidly progressive tumors, despite usually being treated by a multimodal therapy which includes surgery and chemoradiotherapy. We present two patients with PNET of the thorax treated in our clinic. The first patient had a huge tumor in the right hemithorax, which shifted the mediastinum to the contralateral hemithorax. Diagnosis was established by transthoracic fine-needle aspiration biopsy and the tumor was treated by surgical resection. Surgery resulted in a microscopically incomplete resection. Chemoradiotherapy was given postoperatively. The patient had local recurrence after seven months and died of cranial metastasis. The second patient had a small tumor on the right costovertebral angle which protruded towards the skin and was diagnosed by incisional biopsy. The tumor responded very well to preoperative chemotherapy and complete resection was achieved surgically. Postoperative chemoradiotherapy was also given. This patient had bone metastasis, local recurrence and pleural pulmonary metastasis after 6, 18 and 28 months, respectively, and died 30 months after the operation.We discuss the limited effect of surgery on the treatment of thoracic PNET on the basis of the results of these patients in whom we performed surgery.

Dual Perinephric and Prostatic Abscesses from Methacillin-resistant Staphylococcus aureus

Perinephric and prostatic abscesses may present with protean symptoms and often arise from ascending urinary tract infections. Both abscesses are often caused by uropathogens, and only on rare occasions is the etiology due to methacillin-resistant Staphylococcus aureus (MRSA). Perinephric and prostatic abscesses have never been reported to occur together. We present a 56-year-old male with poorly controlled diabetes that had recently begun performing daily self-digital rectal examinations, who presented with a three day history of urinary symptoms. The patient had bilateral costovertebral angle tenderness and a boggy, tender, enlarged prostate. Blood and urine cultures showed MRSA. CT scan of the abdomen and pelvis demonstrated right perinephric abscess and prostatic abscess. This case report illustrates the potential for simultaneous perinephric and prostatic abscesses by MRSA.

Emphysematous Urinary Tract Infections: Diagnosis, Treatment and Survival (Case Review Series)

Emphysematous urinary tract infections are rare conditions, usually occurring in diabetic patients. Mortality rates in medically managed patients are reported to be as high as 70% to 90%. Growth of the diabetic population warrants heightened attention to these potentially fatal infections. We report a series of 5 cases with favorable outcomes. All patients were diabetic. Presenting symptoms included fever, chills, nausea, vomiting, and abdominal pain. On physical examination, two patients had costovertebral angle tenderness; a third was dehydrated; a fourth had dehydration and an abdominal mass; and a fifth patient had suprapubic tenderness. All cases had leukocytosis and impaired renal function. Computed tomography (CT) scan disclosed emphysematous pyelonephritis in 3 cases (gas within renal parenchyma and/or perirenal tissue), emphysematous pyelitis in 1 case (gas in collecting system), and emphysematous cystitis in 1 patient (gas within bladder wall). Urine culture of 1 case grew Enterococci, whereas in the other cases cultures yielded gas-producing organisms. All patients received intravenous antibiotics. Two patients underwent CT-guided abscess drainage; 2 cases had J-stent placement, and one patient was readmitted with septic shock and underwent nephrectomy. All the patients' conditions improved and they were discharged. Emphysematous urinary tract infections are usually caused by gas-producing organisms. They should be suspected in diabetic patients with urinary tract infections and worsening of renal function. CT scan is the method of choice for diagnosis and follow up. None of our patients died, mainly due to early diagnosis, sequential radiologic assessment, and timely surgical intervention when needed.

Características clínicas y de laboratorio en niños con nefrolitiasis: una serie de casos y controles

To evaluate the clinical and laboratory findings in pediatric patients with urolithiasis in a case control study and to obtain variables predicting a low risk of having urolithiasis. Retrospective analysis of 24 cases of children with urolithiasis (age range 3 to 17 years old) admitted to the pediatric emergency room or the hospital ward. Clinical and laboratory information was obtained from the clinical charts and compared with a control group of 29 patients with history of abdominal pain admitted to the hospital. Binary logistic regression and recursive partitioning analysis were used to obtain variables predicting a low risk of having urolithiasis. There was no difference in age, gender, dysuria or nausea (p > 0. 2) between groups. A difference regarding the presence of fever (p = 0.007), haematuria (p = 0.001), costovertebral angle tenderness (p = 0.004), family history (p = 0.007) and abdominal pain lasting more than 48 hs (p = 0.04) was detected. After logistic regression and using recursive partitioning, the presence or history of fever, absence of gross haematuria and no family history of urolithiasis showed a 100% negative predictive value and sensitivity (95% CI 84.7 to 100 and 89.2 to 100 respectively). Children with abdominal pain present a low risk of having urolithiasis if there is a history or presence of fever, absence of gross haematuria and a negative family history of urolithiasis in a first degree relative.

Acute focal bacterial nephritis in an 8‐year‐old girl (Case Report)

Acute focal bacterial nephritis or acute lobar nephronia is an acute localized non-liquefactive bacterial kidney infection. Clinically, it may develop as an abscess and present as acute pyelonephritis but is distinguishable by the presence of a focal mass on imaging studies. The authors report the case of an 8-year-old girl with fever up to 39 degrees C and left flank pain of 6 days duration. On physical examination, she had nothing remarkable except tenderness and knocking pain over the left costovertebral angle. Post-contrast abdominal computed tomography revealed several wedge-shaped hypodense lesions in the left kidney. Urine culture grew Escherichia coli. Acute focal bacterial nephritis was diagnosed. The patient was treated with antibiotics and discharged on the 12th day of hospitalization.

Subcapsular renal hematoma after shock wave lithotripsy

76-year-old man presented to our Emergency Departent with a chief complaint of right flank pain. The atient stated that he had a history of a kidney stone and hat 3 h prior he had undergone extracorporeal shock ave lithotripsy (ESWL) of the right kidney. Before the rocedure the patient reported only mild pain in the ank, but since the procedure his pain had become much ore severe. The patient denied nausea, vomiting, chest ain, or shortness of breath. He had no fevers and denied ematuria. His past medical history was significant for iabetes mellitus, coronary artery disease, and emphyema in addition to nephrolithiasis. His medications inluded insulin, aspirin, rofecoxib, Glucophage, clopiogrel, and cetirizine. Physical examination revealed an elderly man in modrate distress due to pain. Vital signs were: temperature 6.4°C (97.6°F), blood pressure 123/66 mm Hg, heart ate 65 beats/min, and respiratory rate 18 breaths/min. he heart was regular without murmurs and lungs were lear to auscultation. The abdomen was soft and nonender to palpation. There was no hepatosplenomegaly. ack examination revealed right flank percussion tenderess at the costovertebral angle. No bruising was present. he remainder of the physical examination was normal. The patient received morphine 8 mg i.v. for pain. aboratory studies revealed hemoglobin of 13.1 g/dL nd a white blood cell count of 14 K/UL. Urinalysis was ignificant for 100–150 red blood cells. Due to continued

Bladder tenderness as a physical sign for diagnosing cystitis in women

There are few semiotic signs for the diagnosis of cystitis. The costovertebral angle tenderness (CVAT) and vaginal exam have a likelihood ratio (LR) close to 1. Some patients experience a different pain when their bladder is compressed during the vaginal exam. The objectives of this study are to verify the accuracy of bladder tenderness for making the diagnosis of cystitis and if a past history of cystitis or recent sexual intercourse are risk factors for current cystitis. One hundred and ninety female volunteers = 15 years old with or without urinary symptoms were analyzed. The exclusion criteria were recent use of antibiotics and pregnancy. After a standard questionnaire a clean catch midstream urine sample was obtained. Then bladder tenderness was performed using the index finger inside the vagina. It was slid over the upper third of the anterior wall of the vagina compressing the bladder against the opposite hand placed on the suprapubic area. If the patient experienced any kind of pain the test was positive; otherwise it was negative. Urine analysis and culture were standard. (excerpt)

Page kidney: successful radiological management of acute renal failure

Sir, Page kidney is the external compression of a kidney. The condition is usually caused by a subcapsular haematoma, associated with high blood pressure and occasional renal failure, as described by Irwin Page in an animal model with cellophane papers wrapped round the kidney in 1939 and, subsequently, clinically in 1955 [1,2]. The present case illustrates, in a patient with a single functioning kidney, the successful management of a spontaneous subcapsular haematoma that was causing both acute renal failure and hypertension. A 36-year-old female presented with a left-sided loin pain. At the age of 2 years she had undergone right nephrectomy for a Wilm’s tumour and left-sided lower lobectomy for pulmonary metastatic disease, followed by chemotherapy and radiotherapy. Six months before presentation, following her first pregnancy, she was diagnosed with dilated cardiomyopathy, for which she was given candesartan, carvedilol and warfarin. She was in pain, with tenderness over the left costovertebral angle. Her blood pressure was 94/57 mmHg. Investigation showed INR 2.7, C-reactive protein 20 mg/l and serum creatinine 136mmol/l. An ultrasound scan revealed a mixed reflective collection, adjacent to the postero-lateral aspect of her left kidney. Spectral Doppler analysis of the segmental arteries within the kidney showed a high-resistance pattern with complete loss of normal diastolic flow; but the renal vein was patent. A non-contrast computed tomography (CT) scan confirmed the finding of a subcapsular haematoma (Figure 1). In the following 48 h she became hypertensive, oliguric and her serum creatinine rose to 508mmol/l. Drainage was arranged. After reversal of anticoagulation, an 8F pigtail catheter was inserted percutaneously into the haematoma under ultrasound guidance and 100 ml sero-sanguineous fluid was drained. Ultrasound after 24 h showed a reduction in size

Cocaine-induced renal infarction: report of a case and review of the literature

BackgroundCocaine abuse has been known to have detrimental effects on the cardiovascular system. Its toxicity has been associated with myocardial ischemia, cerebrovascular accidents and mesenteric ischemia. The pathophysiology of cocaine-related renal injury is multifactorial and involves renal hemodynamic changes, alterations in glomerular matrix synthesis, degradation and oxidative stress, and possibly induction of renal atherogenesis. Renal infarction as a result of cocaine exposure, however, is rarely reported in the literature.Case presentationA 48 year-old male presented with a four-day history of severe right flank pain following cocaine use. On presentation, he was tachycardic, febrile and had severe right costovertebral angle tenderness. He had significant proteinuria, leukocytosis and elevated serum creatinine and lactate dehydrogenase. Radiographic imaging studies as well as other screening tests for thromboembolic events, hypercoagulability states, collagen vascular diseases and lipid disorders were suggestive of Cocaine-Induced Renal Infarction (CIRI) by exclusion.ConclusionIn a patient with a history of cocaine abuse presenting with fevers and flank pain suggestive of urinary tract infection or nephrolithiasis, cocaine-induced renal infarction must be considered in the differential diagnosis. In this article, we discuss the prior reported cases of CIRI and thoroughly review the literature available on this disorder. This is important for several reasons. First, it will allow us to discuss and elaborate on the mechanism of renal injury caused by cocaine. In addition, this review will demonstrate the importance of considering the diagnosis of CIRI in a patient with documented cocaine use and an atypical presentation of acute renal injury. Finally, we will emphasize the need for a consensus on optimal treatment of this disease, for which therapy is not yet standardized.

All Thats Yellow Is Not Hepatitis

A 25 year old presented with right sided upper abdominal pain associated with vomiting. She was icteric and had a tender RUQ with hepatomegaly. Murphy's sign was absent but had right costovertebral angle tenderness. Laboratory studies revealed an elevated AST, ALT and alk. Phosphatase. Urine showed no pyuria. Hepatobiliary pathology was suspected but hepatitis serology was negative. CT abdomen had a right pelviureteric stone, hydronephrosis, biliary duct dilation and a perinephric abscess (fig 1,2). She had antibiotics and a nephrostomy drainage. An immediate clinical improvement and normalization of LFT's was noted. She was discharged home on TMP/SMX to follow up later. Perinephric abscesses are pus collections surrounding the kidneys. Predisposing conditions are urologic surgeries, UTI's, diabetes and calculi. Common pathogens are the E. coli, if abscess complicates a pyelonephritis, while S. aureus if source is hematogenous. Presentation is with fevers, chills, nausea, vomiting, flank and abdominal pain or masses. Patients can present with obstructive jaundice. Proposed mechanism is extrinsic compression of biliary tree (Fig 1). According to Edelstein H et al. positive urine & blood cultures identify pathogens in 37–58% of patients. Leukocytosis and pyuria are not sensitive or specific. Meng MV and colleagues showed CT scan to be 92% sensitive in diagnosing the site & extent of abscesses. IV pyelograms and ultrasound can be false negative. Treatment entails open or percutaneous drainage. Nephrectomy may be appropriate in staghorn calculi. Initial broad spectrum empiric therapy requires anti staphylococcal penicillin and an aminoglycoside. Further use of antibiotics depend on the pathogen present. Prognosis is good if appropriately treated but in untreated mortality is 40%. [figure 1][figure 2]FigureFigure

A newly described thoracic vascular malformation in fetuses with Down syndrome

To report the association between thoracic vascular malformations observed in the first trimester of pregnancy and Down syndrome. The clinical features were reviewed of seven fetuses undergoing chorionic villus sampling (CVS) for increased nuchal translucency (NT) thickness, in which color Doppler ultrasonography revealed a vascular malformation in the fetal thorax. The crown-rump length of the fetuses ranged from 58 to 78 mm and NT measurements ranged from 2.9 to 10.0 mm. Color Doppler allowed the identification of a highly vascular structure in the posterolateral portion of the fetal thorax, in proximity to the costovertebral angle, at the level of a four-chamber view of the heart. The lesions had a globular shape and were 4-6 mm in diameter, occupying almost one third of the hemithorax. Down syndrome was diagnosed in five out of the seven cases. In the only affected case that underwent postmortem examination, a hemangioma of the chest wall was demonstrated. In the two fetuses with normal karyotype, the lesion disappeared by mid-gestation. We report an association between the prenatal Doppler finding of a vascular tumor in the fetal chest and Down syndrome.

Dyspnea And Chest Pain In An Adolescent - Soccer

HISTORY A 16-year old high school soccer player was running at the conclusion of practice and developed sudden onset dyspnea with retrosternal pain. His shortness of breath and chest pain continued unchanged through the night and he presented to his pediatrician the following morning. There is no history of trauma, fever, cough or asthma. Our patient reported increasing fatigue, abdominal pain, muscle aches, and malaise for two to three days prior to the presenting event. He participated in wrestling during the previous sports season. PHYSICAL EXAMINATION VS: HR 80 bpm, RR 45 breaths/min, BP 135/79 mmHg, Temp 36.6°C, SaO2 97% on room air. General: mild to moderate distress, breathing through pursed lips intermittently, ambulatory and talkative. Cardiovascular: heart - regular rate and rhythm, without murmur, normal pulses, capillary refill is less than two seconds. Pulmonary: lungs clear to auscultation, no increased resonance with percussion, no retractions, crackles or wheezes. Abdomen: mild subcostal tenderness bilaterally, no hepatosplenomegaly, masses or costovertebral angle tenderness, good bowel sounds, soft and nondistended. Extremities: no calf tenderness, Homan's sign was negative. DIFFERENTIAL DIAGNOSIS Spontaneous Pneumothorax Pulmonary Embolism Pericardial tamponade Asthma TEST AND RESULTS Chest radiographs and electrocardiogram: normal Computerized Tomography with contrast of the chest: five pulmonary emboli in the left inferior pulmonary artery and four pulmonary emboli in the right inferior pulmonary artery. No pulmonary infarction, consolidation, atelectasis, or pleural effusion. Transthoracic and transesophageal echocardiograms: normal 2D Doppler, color and spectral Doppler imaging of the neck and extremities: normal D Dimer: 500–1000 Serum coagulopathy work-up otherwise normal FINAL WORKING DIAGNOSIS Bilateral pulmonary emboli secondary to thrombophilia TREATMENT AND OUTCOMES Admitted to pediatric intensive care and anticoagulated with heparin. Anticoagulation with warfarin was initiated and heparin was discontinued. Poor compliance with warfarin and anticoagulation with enoxaparin was initiated. Poor compliance with enoxaparin and patient became symptomatic with dyspnea and retrosternal chest pain. CT scans remained unchanged. Greenfield inferior vena cava filter was placed and anticoagulation with warfarin resumed. Patient developed an essential tremor and major depressive disorder.