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BRIEF CLINICAL OBSERVATIONS

Nondilated Obstructive

Uropathy Due to a

Ureteral Calculus

Aaron Spital, MD, Robert Spataro, MD,

Departments of Medicine and Radiology, University of

Rochester School of Medic ine, The Genesee Hospital,

Rochester, New York

U

trasunography has become the standard ap-

proach for investigating suspected urinary tract

obstruction because of its safety and high sensitivity.lJ

However, it is important to understand that ultra-

sonography does not detect obstruction directly, but

rather its usual consequence: dilatation of the renal

collecting system. Unforhmately, urinary tract ob-

struction is not always accompanied by detectable

dilatation36 In these unusual cases of nondilated ob-

structive uropathy, the results of conventional ultra-

sonography will be falsely negative, thereby mislead-

ing the physician and possibly delaying diagnosis and

therapy. Most previously reported cases have been the

result of retroperitoneal or pelvic malignancy or fi-

brosis, or have followed pelvic surgery.56 Here we re-

port a case of nondilated obstructive uropathy caused

by a ureter-al calculus in order to alert physicians to

the possibility that on occasion, even obstruction due

to a urinary stone may be missed by ultrasonography.

While this presentation has been noted previously by

radiologists,5~7-~ it has not been emphasized in the gen-

eral medical literature.

CASE REPORT

A Wyear-old white male was admitted to The

Genesee Hospital with a Z-day history of intermittent

left-sided flank pain radiating to the groin. His past

medical history included mild renal insufficiency

with a baseline serum creatinine of 1.7 mg/dL, an id-

iopathic lupus anticoagulant, multiple deep venous

thromboses of the legs, and pulmonary emboli.

Medications included coumadin, vitamins, and

herbal preparations. On exarntiation the patient was

found to have new hypertension and left-sided ab-

dominal tenderness. Laboratory data revealed a

serum creatinine of 2.5 m@lL and mild microscopic

hematuria. The patient was thought to have renal

colic, although no stone was seen on abdominal

roentgenography.

The following day, a renal ultrasound was obtained

that was completely normal with no evidence of hy-

dronephrosis (Figure IA). Recause of this surpris-

ing finding and the history of a hypercoagulable state,

occlusive vascular causes of renal dysfunction were

sought. A radionuclide renal scan showed decreased

blood f low to the left kidney with minimal excretion

and a normal-appearing right kidney. Selective left

renal arteriography and venography were performed,

but no evidence of vascular obstruction was found.

The patient’s pain persisted and the serum creati-

nine remained elevated at 2.3 mg/dL. Therefore, the

renal ultrasound was repeated 3 days after the initial

study. Again, no hydronephrosis was detected

(Figure 1B). Nonetheless, because of an increasing

index of suspicion for urinary tract obstruction, an

intravenous pyelogram (IVP) was obtained the fol-

lowing day. It showed delayed excretion on the left

side with mild dilatation of the collecting system and

obstruction at t,he left ureteral vesicle junction

(Figure 2).

On the evening fol lowing the IVP, the patient passed

a small stone that was composed of calcium oxalate.

Figure

1A.

First ultrasound of the left

kidney showing no evidence of

hydronephrosis.

May 1995 The American Journal of Medicine@ Volume 98

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BRiEF CLlNlCAL OBSERVATIONS

Intravenous pyelography has long been consid-

ered the most valuable study for the evaluation of re-

nal colic.277 However, there are several potential com-

plications of this procedure including allergic

reactions, contrast-induced renal failure, precipita-

tion of renal colic, and the consequences of expo-

sure to ionizing radiation. In contrast, ultrasonogra-

phy of the urinary tract is noninvasive and virtually

risk free. Nloreover, some investigators have found

ultrasonography so reliable in the evaluation of re-

nal colic that they have recommended it (rather than

an IS&‘) as the initial study of choice for the investi-

gation of suspected renal paii~.~,~ However, as the pre-

sent case illustrates, this approach will occasionally

be misleading.

Our patient’s initial renal ultrasound was inter-

preted as being completely normal. Even after the di-

agnosis had been made j a retrospective review of this

study still failed to show any abnormality. The nor-

mal findings on ultrasonography, along with reno-

graphic evidence of unilateral poor function and a his-

tory of hypercoagulability, led the physicians to

perform unnecessary

invasive

procedures to exclude

vascular obstruction as the cause of this patient’s dis-

order. A repeat renal ultrasound several days later

was again norm@ but an IVP clearly showed ob-

struction at the left ureteral vesicle junction.

This unusual presentation of renal calic secondary

to an obstructing

stone

with

no

detectable dilatation

on ultrasonography has been previously alluded to

in the radiological literature.1~G~“8 In most cases, the

reporting physicians concluded that the obstruction

was very recent and proximal dilatation had not yet

had time to occur. However, our case suggests that

.,., ._ ., .,

F@re 13. Second ultrasound o f the left kidney again show&

no

hydronephrosis.

The next day, the serum creatinine returned to its pre-

vious baseline value of 1.7 mgML. Three weeks later

a repeat radionuclide renal scan was normal

Figure 2. Thirty-minute oblique radiograph from the intravenous

pyelogram showing blunted fornices with mildly dilated calyces,

renal pelv is, and proximal ureter of the left kidney, consistent

with ureterai obstruction. The right side is normal.

there are other causes of nondilatation in obstruc-

tive nephrolithiasis. Our patient had more than 2 full

days of renal colic before his initial normal sono-

graphic study. The process had been present for 5

days at the time of his second study. These results

are even more impressive when one considers that

the degree of obstruction was severe, as evidenced

by the renographic and urographic findings as well

as the elevation in serum creatinine. The explanation

for this remarkable presentation is unknown.

Previously proposed mechanisms include: impaired

peristalsis; for&al rupture with decompression of

the pelvicalyceal system; atypical anatomy of the col-

lecting system (such as a small intrarenal pelvis)

which resists dilatation; and a severely depressed

glomerular filtration rate secondary to underlying re-

nal disease or volume depletion.1~3-5~BJ0

Regardless of the mechanism, the message is clear.

When a patient presents with renal colic and an ob-

structing urinary

stone

is suspected, the physician

should not be dissuaded by negative findings on ul-

tmsonography. In such cases, an IVP should be per-

formed. Indeed, because of the possibility of nondi-

latation and because the IW can

better define the site

510 May 1995 T he American Journal of Medicine@ Volume 98

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BRIEF CLINICAL OBSERVATIONS

and cause of obstruction, many authors still believe

that

the

IVP is the diagnostic procedure of choice in

t.he evaluation of renal colic.‘a”,g In those rare situa-

tions where urography is contraindicated and ultra-

sonography is normal, retrograde and even antegrade

pyelography should be considered.

REFERENCES

1. Cronan JJ. Contemporary concep ts for lmaglng urinary tract obstruction.

UroiRadiol. 1992;14:8-12.

2. Webb JAW . Ultrasonography In the dlagno sls of renal obstruction. EIMJ.

1990;301:944-946.

3. Gornish M, Lune Y, Wysenbeek AJ. Nondilated obstructive uropathy causing

acute renal failure. Isr J Med SC;. 1990;26:50-52.

4. Lyons K, Matthews P, Evans C. Obstructive uropathy without djlatabon: a

potential dlag nostlc pitfall. BMJ. 1988;296:1517-1518.

5. Malllet PJ, Pelle-Francoz 0, Laville M, et al. NondIlated obstructive acute

renal failure: diagnos tic procedures and therapeutic management. Radiology.

1986;160:659-662.

6. Spital A, Valve JR, Segal AJ. Nondilated obstructive uropathy. Urology.

1988:31:478-482.

7. Erwin BC, Carroll BA, Sommer FG. Renal COIIC: the role of ultrasound In initial

evaluation. Radiology. 1984;152:147-150.

8. Haddad MC, Sharlf HS , Shahed MS, et al. Renal colic: dlagnosrs and

outcome. Radiology. 1992;184:83-88.

9. Spencer J, Lindse ll 0, Mastorakou I. Ultrasonography compared with

Intravenous urography in the investigation of adults with hematurla. BMJ.

1990;301:1074-1076.

10. Platt JF, RubIn JM, EIIIs JH. Acute renal obstruction: evaluation with

lntrarenal duplex doppler and conventional US. Radiology. 1993;186:685688.

Manuscript submltted April 20, 1994

and accepted June 22, 1994.

Trousseau’s Syndrome With

Nonbacterial Thrombotic

Endocarditis: Pathogenic

Role of Antiphospholipid

Syndrome

Didier Bessis, MD, Albert Sotto, MD, t @ital

Saint-

E/o;,Montpellier,Jean-Paul Viard, MD, HbpitalNecker,

Paris,Madeleine Bbard, PhD, HdpitalSaint-Louis,

Paris,

Albert-Jean Ciurana, MD,

/ pita/ Saint-E/o;,

Montpellier,

Marie-Claire Boffa, MD, PhD,

&pita/

Saint-Louis, aris,France

N

onbacterial thrombotic endocarditis (NBTE)

with Trousseau’s syndrome is a common mani-

festation of malignant diseases, particularly in lung,

gastrointestinal, and pancreatic adenocarcinomas.’

The pathophysiologic mechanisms of these malig-

nancy-associat.ed thromboses are still

not

clear. We

describe a case of NBTE with Trousseau’s syndrome

in a patient with lung adenocarcinoma. The patient

was positive for antiphosphatidylinositol antibodies

and anti-@ glycoprotzin I (anti-PBGPI) antibodies; to

the best of our knowledge, this combination has

never been reported in this pathology.

CASE REPORT

In

July 1992, a previously healthy 48-year-old white

man

presented with aphasic right palsy that re-

gressed within a fe w minutes. Five days later, he

complained of severe pain in his left calf and apha-

sic left facial palsy. Digital subtraction angiography

of

the

abdominal aorta and lower limbs revealed

em-

bolic obliteration of the left tibioperoneal artery. A

cerebral computed tomographic (CT) scan showed

vascular ischemic in&uy of the right temporal and bi-

lateral occipital lobes and t,he left internal capsule.

The patient was given intravenous heparin for I1

days followed by warfar in. One week later,

he

had a

fever of 38.5”C and complained of cramps in his left

leg. A superficial venous thrombosis was noted in

the

upper left arm. Venography of the lower limbs re-

vealed thromboses of the bilateral popliteal and tib-

ial veins.

On admission to Hepital Saint-Eloi (Montpellier,

France) 1 month later, the physical examination re-

vealed a systolic murmur in the mitral region and

aphasia with confusional syndrome. The white blood

cell count was 16 X log/L with 68% polymorphonu-

clear leukocytes. No thrombopenia or fibrinopenia

was observed. Nine blood cultures were sterile.

Serologic tests for HIV-l and HIV-2, Q fever,

Chlamydia~, Mycoplasma,

and Rmtcellu species were

negative. Venereal Disease Research Laboratory test,

Coombs’ test, rheumatoid factor, antibodies to nu-

clear components and native DNA, and antineu-

trophil cytoplasmic autoantibodies were negative.

Lupus anticoagulant was detected with a pro-

longed partial activated thromboplastin time (49 sec-

onds versus 32 seconds for

the

control), uncorrected

by mixing with normal plasma, and confirmed by

measuring prothrombin time using diluted thrombo-

plastin. The levels of coagulation proteins (factors II,

V, VII, VIII,

IX, X,

XI, XII), antithrombin III, protein

C, and protein S were normal.

Antiphospholipid antibody (aPLA) levels were de-

termined (INSERM U353 and Dr. Pascale Laroche,

Biomedical Diagnostics, Marne-la-Vallke, France)

using

an

enzyme-linked immunosorbent assay

(ELISA) on plates coated with different: phospho-

lipids: cardiolipin,

phosphatidylinositol, phos-

phatidylserine, phosphatidylethanolamine, either

alone or in combination (Table). The aPLA levels

were expressed as GPL or MPL units using a stan-

dard curve obtained with serially diluted selected

positive sera. Ten unit,s, which corresponded to the

97th percentile of the distribution of 100 healthy

blood donors, was arbitrarily chosen as the thresh-

old above which aPLA levels were considered to be

May 1995 The American Journal of Medicinea Volume 98

511