Pelvic organ prolapse (POP) is the descent of pelvic organs through the vagina, and sometimes causes hydronephrosis. Although the association between POP and hydronephrosis has long been recognized, severe hydronephrosis and renal dysfunction are rarely seen. We report a case of 66-year-old woman who had a vaginal delivery presented with externalized uterine and bladder prolapse during the previous 2 years. She had a 3-day history of hypophagia and vomiting, and laboratory analysis resulted in serum creatinine of 5.75 mg/dL and blood urea of 78.1 mg/dL. The patient was treated urgently with vaginal pessary to return the uterine and bladder into the pelvis. After 2 weeks, her serum creatinine dropped to 3.66 mg/dL, but chronic renal failure persisted. Hydronephrosis caused by POP may lead to renal dysfunction and can advance to irreversible renal damage if left untreated. Important is early evaluation of renal function and images of the kidney and ureter.
Keywords: hemodialysis, A 3243 G point mutation of the mitochondrial tRNAleu gene, mitochondrial disease, mitochondrial myopathy, encephalopathy, lactic acidosis, stroke-like episodes(MELAS) 〈Abstract〉 The patient started receiving hemodialysis for renal dysfunction at the age of 59 years. During the same period, he was found to have cardiac dysfunction and type 2 diabetes. Without performing a renal biopsy, a clinical diagnosis of diabetic nephropathy was made. However, mitochondrial disease was suspected based on the presence of a headache, vomiting, sensorineural hearing loss, emaciation, declining intelligence, repeated blood lactic acid measurements of>2 mmol/L, and heart disease in patient's mother. Genetic tests were conducted when the patient was 65 years old. A tRNA-Leu (UUR) 3243A→G mutation was detected, and mitochondrial myopathy, encephalopathy, lactic acidosis, stroke-like episodes was suspected. Afterward, the patient suffered prolonged hypoglycemia and died. An autopsy was performed, but no morphological lesions that could account for the hypoglycemia were found. The patient's kidneys were in a severely damaged state, and it was difficult to determine the precise lesion that had caused his renal failure, but it is possible that the renal failure was related to his mitochondrial disease. Many abnormal mitochondria were seen during an examination of the patient's myocardial and choroid plexus epithelial cells performed with an electron microscope, and pathological findings that were indicative of mitochondrial disease were also detected.
Obturator hernia is a rare condition that commonly affects frail older women. A 54-year-old woman presented to our hospital with left hip joint pain. She had suffered a left pubic bone fracture and commenced maintenance hemodialysis. Pelvic computed tomography (CT) showed an incarcerated small intestine through the left obturator foramen, while abdominal CT showed marked intestinal dilatation. She underwent emergency laparotomy, and the incarcerated small intestine was found to be necrotic. Partial small intestinal resection and bilateral obturator hernioplasty were performed. Because obturator hernia is a potentially fatal condition, early detection and treatment are important.
A 73-year-old man was admitted to our hospital for bilateral foot pain and an elevation of serum creatinine level from 0.96 to 1.59 mg/dL for two months. He had been treated for hypertension, diabetes mellitus and dyslipidemia. He had history of cerebral angiography two months before admission. Laboratory data revealed that C reactive protein was elevated and eosinophilia was present. Cyanosis was present in the bilateral toes. Skin biopsy of the right toe revealed needle-shaped clefts and leukocytoclastic vasculitis in dermal arterioles (Picture 1) which is a characteristic finding of cholesterol crystal embolism (CCE). He had no eye symptoms but the diagnosis of CCE was confirmed by the finding of a bright yellow cholesterol plaque (hollenhorst plaque) at the bifurcation of the retinal arteriole (Picture 2). A hollenhorst plaque apparently consists of embolic material from atheromatous lesions in the aorta or carotid arteries (1). The identification of a hollenhorst plaque can lead to the diagnosis of CCE. The authors state that they have no Conflict of Interest (COI).Reference 1. Hollenhorst RW. Significance of bright plaques in the retinal arterioles. JAMA 178: 23-29, 1961.
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