Renal Papillary Necrosis Appearing as Bladder Cancer on Imaging

Abstract

A 79-year-old woman with a history of diabetes mellitus and recurrent urinary tract infections (UTIs) presented with acute onset left lower quadrant pain, left-sided back pain, vomiting, and dysuria. Abdominopelvic CT scan revealed left hydroureteronephrosis to the level of the left ureterovesical junction (UVJ) where a bladder mass appeared to be obstructing the left ureteral orifice. The obstruction was ultimately found to be the result of a sloughed renal papilla lodged in the distal ureter, which created an inflammatory mass at the UVJ. Her history of diabetes and frequent UTIs likely predisposed her to the development of renal papillary necrosis (RPN) that resulted in sloughing of a renal papilla, distal ureteral obstruction with subsequent bladder inflammation that mimicked a bladder mass on imaging. RPN is a condition associated with many etiologies and likely represents a common final pathway of several diseases. Although several hypotheses exist, it is primarily thought to be ischemic in nature and is related to the underlying physiology of the renal papillae. We present a case of hydroureteronephrosis and bladder mass secondary to a sloughed renal papilla from RPN.

Necrosis papilar renal bilateral de resolución espontánea como causa de hematuria microscópica. Caso clínico

“…Otras entidades frecuentemente asociadas a la NPR son la diabetes mellitus, la hiperbilirrubinemia crónica y la tuberculosis genito-urinaria 10 . La nemotecnia "POSt-CARDS" (pielonefritis, obstrucción, sickle cell anemia, tuberculosis, cirrosis, abuso de analgésicos, renal vein trombosis, diabetes mellitus, systemic vasculitis) puede orientar a la búsqueda de la causa de la NPR 13 .…”

“…Estudios de laboratorio realizados a la paciente, descartándose la asociación con patologías relacionadas a Npr 5,6,11 Se debe tener un alto índice de sospecha clínica de esta entidad, ya que en general es una patología con sintomatología escasa y forma de presentación inespecífica, especialmente en los casos de evolución crónica. Los pacientes pueden consultar por síntomas como cefalea, dolor abdominal, nicturia, disuria, dolor lumbar y cólico ureteral 13 . En el examen de orina completa se puede encontrar hematuria, piuria y bacteriuria en grados variables, no siendo infrecuente la pesquisa de piuria aséptica 14 .…”

Obstructive Pyelonephritis in a Diabetic Think Sloughed Papilla!

“…3 One more recent case report describes a similar presentation of a woman with diabetes being investigated for a bladder mass which had formed as a consequence of sloughed renal papillae. 4 Further data collection on the incidence and presentation of this complication in diabetes specifically could be beneficial to future potential interventions either in preventative or treatment measures, with prevention of recurrence also being an important consideration for future work. There does not at present appear to be conclusive literature on predictive factors such as HbA1c for developing RPN in diabetes though some have examined the imaging techniques which may best detect cases such as this.…”