Bacterial endocarditis presenting with unilateral renal artery occlusion treated with the Rinspirator Thrombus Removal System rinsing and thrombectomy device and suction thrombectomy

Abstract

We report a 36-year-old man who presented with unilateral flank pain caused by renal artery occlusion with ischemia and infarction from septic emboli secondary to bacterial endocarditis. We treated the occlusion with a novel rinsing and aspiration device, the Rinspirator Thrombus Removal System (ev3, The presentation of flank pain in younger patients may be secondary to a variety of etiologies such as renal, musculoskeletal, or dermatologic processes, with common causes being renal colic from infection or urolithiasis. Renal ischemia and infarction due to emboli is a rare cause of flank pain. Treatment of acute embolic events to the kidney must proceed rapidly to prevent loss of renal tissue. We present a case of a young man who presented with acute flank pain secondary to septic emboli from bacterial endocarditis with infarction and ischemia of a unilateral kidney. The affected renal artery was revascularized using the Rinspirator Thrombus Removal System (ev3, Plymouth, Minn) device and suction thrombectomy. Institutional Review Board approval was not required for this report.Plymouth CASE REPORTA 36-year-old man presented to a local emergency department complaining of extremity pain and paresthesias, abdominal pain localizing to his right flank, fever, chills, night sweats, nausea, and vomiting. An abdominal computed tomography (CT) scan with contrast demonstrated a striated nephrogram appearance of the right kidney and a normal left kidney (Fig 1). The differential diagnosis included ischemia, infection, or obstruction. The next morning, the patient was transferred to our institution for further evaluation.Laboratory data on admission demonstrated a white blood cell count of 22,100 (reference range, 3.4-9.8ϫ [10] 3 ), creatinine level of 1.5 mg/dL (reference range, 0.7-1.3 mg/dL), measured glomerular filtration rate of 61.9 mL/min (reference range, Ͼ60 mL/min), and a lactate dehydrogenase (LDH) level of 1799 U/L (reference range, 110-213 U/L). A urinalysis demonstrated large amounts of blood, proteinuria, and 1ϩ bacteria per high-power field. Results of blood cultures were negative. Physical examination revealed right flank pain and splinter hemorrhages of the nail beds. Gadolinium-enhanced renal magnetic resonance imaging demonstrated apparent occlusion of the right renal artery and multiple renal infarcts. Heparin therapy was started, and an arteriogram was requested approximately 48 hours after admission.Standard arteriogram risks and treatment options to include thrombectomy and thrombolysis, and alternative surgical options were discussed, and a signed consent was obtained. A nonselective renal arteriogram was performed to delineate the extent of narrowing or occlusion of the right renal artery and possible therapeutic options. The arteriogram demonstrated multiple filling defects in the right renal artery, with antegrade flow and areas of hypoperfusion. The left renal artery appeared normal.The findings were consistent with an embolic source, and treatment was instituted to prevent possible migration an...

Infective endocarditis presenting with loin pain

“…The most common aetiology of clinically significant renal infarction includes embolism due to cardiogenic causes and renal trauma 3 4. Although clinically symptomatic renal emboli is rare in patients with endocarditis, postmortem study of patients found septic emboli in 24–31% of patients 5…”

“…Lactate dehydrogenase, as an indicator of cell necrosis, has shown to be the most sensitive laboratory finding in cases of renal infarction although not specific to cases of endocarditis 3 8. CT scanning is accepted as the appropriate imaging modality replacing angiography, which has been considered the gold standard 3 4 9 10…”

Septic Embolism: A Potentially Devastating Complication of Infective Endocarditis

“…Despite numerous case reports, available clinical data on SE to the kidneys continue to be limited [2,[69][70][71]. Embolic events associated with IE involve kidneys in 6-14% cases (Figure 1) and exhibit highly variable pattern of presentation [2,69].…”

“…Three types of severe renal manifestations may be seen: renal infarcts, focal "embolic" glomerulonephritis, and acute diffuse glomerulonephritis [72]. Renal loss due to embolic occlusion of the renal artery has been reported [71]. Of interest, localized renal infarcts were found in over 30% of necropsy samples, with more than half attributable to SE in patients infected with Staphylococcus aureus [69].…”