MedPix Medical Image Database

COW - Case of the WeekCase Contributor: Natalia P GaulkeAffiliation: Childrens Hospital of Dayton, OH

MedPix No: 14432 - HistoryPt Demographics: Age = 2 y.o. Gender = boy2 y.o otherwise healthy male presents to ED with complain of dark urine for last 2 days and one episode of clot seen in urine. Per parents, the patient fell down off the couch approximately 10 days ago, otherwise no recent history of trauma, fever, respiratory symptoms, gastrointestinal problems or rash. Patient has good appetite and normal pattern of sleep. No apparent complaints of pain, per parents.

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MedPix No: 14432 - EXAM & LABSReview of Systems: All pertinent ROS are negative - except hematuria. Negative for flank pain. NKANo current medications.PMH: no significant past medical historyPhysical exam:Pulse: 136Temp: 36.9CResp: 24Weight: 15.876 kgConstitutional: well developed, well nourished male, active, NKDHENT: WNLCardiovascular: normal rate and rhythm.Pulmonary: WNLAbdomen: Full on palpation, distended, + palpable left upper quadrant abdominal mass. No guarding or rigidityGU: WNLMSK: WNLNeuro: alert, orientedSkin: warm to palpation, no rashLaboratory: (*) - abnormalWBC COUNT 19.6 (*) RBC COUNT 4.45 HEMOGLOBIN 11.2 (*) HEMATOCRIT 34.7 MCV 78 MCH 25.2 MCHC 32.3 RDW 14.9 (*) MPV 7.1 PLATELET COUNT 589 (*) HEMO SLIDE NUMBER 26 SEGMENTED NEUTROPHIL 52.0 (*) LYMPHOCYTE 37.0 (*) MONOCYTE 9.0 (*) EOSINOPHIL 2.0 ABSOLUTE NEUTR. CNT. 10.19 RBC MORPHOLOGY NORMOCHROMIC/NORMOCYTIC DIFFERENTIAL TYPE MANUAL DIFFERENTIAL COMPREHENSIVE METABOLIC PANEL SODIUM 137 (*) POTASSIUM 5.2 CHLORIDE 106 (*) CARBON DIOXIDE, TOTAL 20.6 GLUCOSE,RANDOM 107 (*) BLOOD UREA NITROGEN 7 (*) CREATININE 0.4 CALCIUM 9.9 ALBUMIN 3.9 ALKALINE PHOSPHATASE 144 TOTAL BILIRUBIN 0.5 AST 58 (*) TOTAL PROTEIN 7.4 ALT 15 URINALYSIS W MICROSCOPIC URINE VOLUME 12.0ml URINE BACTERIA 2+ CORRESPONDS TO 11 TO 100 BACTERIA/HPF AMORPHOUS SEDIMENT 1+ NOT SIGNIFICANT IF PRESENT IN NON-FRESH URINES URINE SULFASALICYLIC ACID 50 (*) WHITE BLOOD CELLS 5 TO 7 RED BLOOD CELLS >50 (*) URINE SOURCE UCC CLEAN CATCH URINE COLOR RED URINE APPEARANCE BLOODY URINE SPECIFIC GRAVITY 1.013 URINE GLUCOSE Negative URINE BILIRUBIN MODERATE (*) URINE KETONES Negative URINE BLOOD LARGE (*) URINE pH 7.5 URINE PROTEIN 100 (*) UROBILINOGEN 0.2 URINE LEUKOCYTE ESTERASE TRACE (*) URINE NITRITE Negative IMMUNOGLOBULINS IGG IGA IGM IGG 951 IGA 75 IGM 153 C3 COMPLEMENT COMPLEMENT C3 189.0 (*) RENAL FUNCTION PANEL SODIUM 136 (*) POTASSIUM 3.9 CHLORIDE 101 CARBON DIOXIDE, TOTAL 25.6 GLUCOSE,RANDOM 93 BLOOD UREA NITROGEN 8 (*) CREATININE 0.3 (*) CALCIUM 9.8 ALBUMIN 3.8 PHOSPHOROUS 5.2

CT abd/pelvis with contrast

Multiple nodules within lung bases

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT abd/pelvis with contrast

Heterogeneous renal mass

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CT chest with contrast

Left apical nodule

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CT chest with contrast

Left apical nodule

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CT chest with contrast

Left apical nodule

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CT chest with contrast

Left apical nodule

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CT chest with contrast

Left apical nodule

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CT chest with contrast

right middle lobe nodule

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Renal Doppler US

Partial visualization of proximal left renal vein. Distal left renal vein is obscured by left renal mass.

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Renal Doppler US

The IVC is patent without evidence for thrombosis.

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FINDINGSCT ABDOMEN/PELVIS WITH CONTRAST:Lung Bases: A 7mm nodule within the lingula and 12 mm nodule within right lung base. No pleural effusions are seen. Abdomen:Large heterogenous mass arising from mid anterior left kidney, measures up to 10.1 cm transverse x 9.6 cm AP x 10.3 cm CC dimensions. Mass exhibits central low attenuation, non-enhancing regions suggestive of necrosis. It causes displacement of the nearby organs and compression of left renal vein. No visualized thrombus within the IVC. The right kidney exhibits normal enhancement without evidence of mass. CT CHEST WITH CONTRAST:Multiple pulmonary nodules demonstrated. The largest are: 3.4 x 2.4 x 2.9 cm within left lung apex causing compression of apicoposterior bronchus; a 5 mm nodule within left upper lobe and 9 mm nodule within lingula adjacent to the cardiac margin; 4 mm nodule in posterior right lower lobe and 8 mm nodule within right middle lobe. No hilar or mediastinal lymphadenopathy is demonstrated. US RENAL DOPPLER:Only proximal aspect of the left renal vein is visualized, the distal portion is obscured by large left renal mass. The visualized portion of the left renal vein demonstrates normal Doppler flow without evidence of thrombus. The IVC, right renal vein, splenic, portal and hepatic veins have normal appearance.

DIFFERENTIAL DIAGNOSISWhat is your Differential Diagnosis? Wilms Tumor with lung metastasis, stage IV- Neuroblastoma- Mesoblastic nephroma -

Diagnosis: Wilms tumor, Stage IVDx Confirmed by: Imaging

DISCUSSION