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Practice
Interactive case report 70 year old man with scrotal swelling, abdominal aortic aneurysm, and renal lesions: case report Saroj Kumar Das, Devdatta Sarwate, J K Mordani, K J Ng, Mark Nel Mr Mahon is a 70 year man who was referred to vascular outpatients by his general practitioner. He complained of a scrotal swelling, which had developed gradually over several months and was causing slight discomfort in his daily activities. He was obese and had a hydrocele on the right side of the scrotum and a small varicocele on the left. Mr Mahon handed us a report from ultrasonography of his abdomen and scrotum that his general practitioner had requested. This reported an abdominal aortic aneurysm, measuring about 7 cm at the widest point (anterior-posterior). In addition, an eccentric complex cyst was evident in the interpolar region of the left renal cortex, with no signs of hydronephrosis. The right kidney had multiple simple cysts.
Medical history Mr Mahon is a retired labourer and spends most of his time with his family. He had a myocardial infarction in 2001, after which he was started on low dose aspirin. He also has chronic asthma that is well controlled by inhalers and hypothyroidism treated with thyroxine. He had hypertension diagnosed some 10 years ago, and this was well controlled with a diuretic and angiotensin converting enzyme inhibitor. He had participated in a simvastatin trial for secondary prevention after an episode of acute coronary syndrome. He had stopped smoking 10 years before presentation to outpatients. Two years ago Mr Mahon had had a urinary tract infection, after which he developed prostatic symptoms with hesitancy, poor flow, and post-micturition dribbling. His general practitioner prescribed finasteride and referred him to the prostate clinic for further evaluation. Digital rectal examination, normal uroflowmetry, and prostate specific antigen testing ruled out any serious prostate problem.
Current investigations To get a clearer picture of the renal lesions, Mr Mahon had triple phase, contrast enhanced computed
Questions 1 What is the most likely cause of the renal findings and why? 2 Is Mr Mahon’s presentation related to the renal lesion? 3 Is abdominal and scrotal ultrasonography cost effective and clinically effective in patients like Mr Mahon? 4 What other investigations would you do to guide further management? Please respond through bmj.com, remembering that Mr Mahon is a real patient and that he and his carers will read your response
Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN Saroj Kumar Das consultant vascular surgeon Devdatta Sarwate senior house officer J K Mordani consultant radiologist K J Ng consultant urologist Mark Nel consultant anaesthetist Correspondence to: S K Das saroj.das@ imperial.ac.uk BMJ 2006;332:899
tomography. This confirmed an 8 cm infrarenal abdominal aortic aneurysm. The left kidney had a 2.8 cm eccentric solid mass arising from the posterior mid-pole region of the renal cortex, with heterogeneous enhancement. A simple cyst arising from the lower pole of the left kidney was also noted. Multiple simple cysts were seen in the right kidney with one large 5.5 cm cyst replacing much of the lower pole cortex. He had no retroperitoneal lymphadenopathy or renal vessel disease (figure). Competing interests: None declared. (Accepted 2 December 2005)
This is the first of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. Next week we will report the case progression and in four weeks’ time we will report the outcome and summarise the responses
Computed tomography of abdomen showing 2.8 cm mass in the left renal cortex (left); well defined cysts in both kidneys (centre); large aortic aneurysm (right)
