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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{SSK}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Renal
|SubCategory=Renal
|Prompt=A 23 year old Caucasian female patient presents to the emergency department with a one day history of confusion and altered level of consciousness. Appropriate history could not be taken due to the patient’s condition. Patient’s vital signs are immediately taken. Her temperature is 39.5 degrees C (103.1 degrees F). Her heart rate is 102 beats per minute and her blood pressure is 90/50 mmHg. On physical examination, the patient has a petechial rash and nuchal rigidity. Blood cultures are taken and appropriate antibiotic therapy is immediately initiated. Blood cultures reveal group B Neisseria meningitidis. Patient’s condition gradually improves. Despite fluid resuscitation, the patient remains anuric. Abdominal computed tomography (CT) scan will reveal which of the following findings in this patient?
|Prompt=A 23-year-old Caucasian woman patient presents to the emergency department for confusion and altered level of consciousness. Appropriate history could not be taken due to the patient’s condition. Her temperature is 39.5 ᵒC (103.1 ᵒF), heart rate is 102/min and blood pressure is 90/50 mmHg. Physical examination reveals a petechial rash on predominantly on the lower extremities and significant nuchal rigidity. Blood cultures are withdrawn and broad spectrum antibiotic therapy is immediately initiated. The patient’s condition gradually improves over the next few days, but she remains anuric despite appropriate hydration. Blood cultures reveal 2 organisms: ''Neisseria meningitidis'' and ''Staphylococcus epidermidis''. What is the most likely finding on CT scan in this patient?
|Explanation=Bilateral renal cortical necrosis is a rare phenomenon characterized by bilateral renal infarcts. It is a complication of vascular insult to the arteries that supply the renal cortex. Sepsis and disseminated intravascular coagulation (DIC) are typical inciting events. Pregnancy-related complications are frequently implicated in renal cortical necrosis as well. Other causes include drugs and trauma.  
|Explanation=Bilateral renal cortical necrosis is a rare phenomenon caused by significantly diminished renal arterial perfusion secondary to vascular injury, spasm, or coagulopathy. Sepsis, disseminated intravascular coagulation (DIC), and pregnancy-related complications are typical inciting events for renal cortical necrosis. Other causes include drugs and blunt trauma. Contrast-enhanced computed tomography (CT) is the imaging of choice to diagnose renal cortical necrosis.  CT scan reveals acutely hypo-dense areas in the renal cortex bilaterally with enhancement of subcapsular and juxtamedullary areas. Care should be taken with these patients as further injury from contrast media administration is possible. Chronic kidney disease develops up to 50% of patients requiring long term dialysis and transplantation. Partial recovery of renal function is a possibility in certain patients. The mortality rate from renal cortical necrosis exceeds 50% in untreated patients.  
 
Contrast-enhanced computed tomography (CT) is the imaging of choice to diagnose renal cortical necrosis.  CT scan reveals acutely hypo-dense areas in the renal cortex bilaterally. Renal replacement therapy is an effective therapy for many patients who suffer from renal cortical necrosis, but partial recovery is also possible.
|AnswerA=Bilateral renal infarcts
|AnswerA=Bilateral renal infarcts
|AnswerAExp=Bilateral renal cortical necrosis is characterized by renal infarcts. In is a rare complication of DIC, pregnancy, and sepsis, trauma, and drugs.
|AnswerAExp=Bilateral renal cortical necrosis is characterized by renal infarcts. In is a rare complication of DIC, pregnancy, and sepsis, trauma, and drugs.
|AnswerB=Adrenal hemorrhage
|AnswerB=Adrenal hemorrhage
|AnswerBExp=Adrenal hemorrhage followed by adrenal gland failure is characteristic of “Waterhouse-Friderichsen” syndrome. Although the syndrome is also commonly due to N. meningitidis, symptoms of adrenal insufficiency would be prevalent, such as abdominal pain, hypotension, hyponatremia, and hyperkalemia. The patient’s general status improvement without additional intervention and urinary findings favor bilateral renal cortical necrosis in this case.
|AnswerBExp=Adrenal hemorrhage followed by adrenal gland failure is characteristic of Waterhouse-Friderichsen syndrome. Although the syndrome is also commonly due to N. meningitidis, symptoms of adrenal insufficiency would be prevalent, such as abdominal pain, hypotension, hyponatremia, and hyperkalemia. The patient’s general status improvement without additional intervention and urinary findings favor bilateral renal cortical necrosis in this case.
|AnswerC=Shrunken kidney size bilaterally
|AnswerC=Shrunken kidney size bilaterally
|AnswerCExp=Shrunken kidney size bilaterally is a characteristic finding of chronic kidney disease (CKD). Given the patient’s acute history, shrunken kidneys are unlikely to be present on CT scan.
|AnswerCExp=Shrunken kidney size bilaterally is a characteristic finding of chronic kidney disease (CKD). Given the patient’s acute history, shrunken kidneys are unlikely to be present on CT scan.
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|AnswerDExp=Thyroidization of the kidney is a finding on renal biopsy that is commonly found in several chronic renal diseases. The process is characterized by renal tissue that resembles that of thyroid on renal biopsy under light microscopy.
|AnswerDExp=Thyroidization of the kidney is a finding on renal biopsy that is commonly found in several chronic renal diseases. The process is characterized by renal tissue that resembles that of thyroid on renal biopsy under light microscopy.
|AnswerE=Dilation of renal pelvis and calyces
|AnswerE=Dilation of renal pelvis and calyces
|AnswerEExp=Hydronephrosis is characterized by the dilation of renal pelvis and calyces. The patient’s presentation is not compatible with hydronephrosis
|AnswerEExp=Hydronephrosis is characterized by the dilation of renal pelvis and calyces. The patient’s presentation is not compatible with hydronephrosis.
|EducationalObjectives=Bilateral renal cortical necrosis is a rare complication of pregnancy-related medical conditions and sepsis. Contrast-enhanced CT scan is the imaging reveals bilateral renal infarcts that confirms the diagnosis.
|EducationalObjectives=Bilateral renal cortical necrosis is a rare complication of pregnancy-related medical conditions and sepsis. Contrast-enhanced CT scan is the imaging reveals bilateral renal infarcts that confirms the diagnosis.
|References=Chervu I, Koss M, Campese VM. Bilateral renal cortical necrosis in two patients with Neisseria meningitidis sepsis. Am J Nephrol. 1991;11(5):411-5
|References=Chervu I, Koss M, Campese VM. Bilateral renal cortical necrosis in two patients with Neisseria meningitidis sepsis. Am J Nephrol. 1991;11(5):411-5
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=Renal, Renal cortical necrosis
|WBRKeyword=Renal, Renal cortical necrosis, Kidney, DIC, AKI, Acute kindye injury, Sepsis
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 00:21, 28 October 2020

 
Author [[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Renal
Prompt [[Prompt::A 23-year-old Caucasian woman patient presents to the emergency department for confusion and altered level of consciousness. Appropriate history could not be taken due to the patient’s condition. Her temperature is 39.5 ᵒC (103.1 ᵒF), heart rate is 102/min and blood pressure is 90/50 mmHg. Physical examination reveals a petechial rash on predominantly on the lower extremities and significant nuchal rigidity. Blood cultures are withdrawn and broad spectrum antibiotic therapy is immediately initiated. The patient’s condition gradually improves over the next few days, but she remains anuric despite appropriate hydration. Blood cultures reveal 2 organisms: Neisseria meningitidis and Staphylococcus epidermidis. What is the most likely finding on CT scan in this patient?]]
Answer A AnswerA::Bilateral renal infarcts
Answer A Explanation AnswerAExp::Bilateral renal cortical necrosis is characterized by renal infarcts. In is a rare complication of DIC, pregnancy, and sepsis, trauma, and drugs.
Answer B AnswerB::Adrenal hemorrhage
Answer B Explanation [[AnswerBExp::Adrenal hemorrhage followed by adrenal gland failure is characteristic of Waterhouse-Friderichsen syndrome. Although the syndrome is also commonly due to N. meningitidis, symptoms of adrenal insufficiency would be prevalent, such as abdominal pain, hypotension, hyponatremia, and hyperkalemia. The patient’s general status improvement without additional intervention and urinary findings favor bilateral renal cortical necrosis in this case.]]
Answer C AnswerC::Shrunken kidney size bilaterally
Answer C Explanation AnswerCExp::Shrunken kidney size bilaterally is a characteristic finding of chronic kidney disease (CKD). Given the patient’s acute history, shrunken kidneys are unlikely to be present on CT scan.
Answer D AnswerD::Tubular eosinophilic casts that look like thyroid tissue
Answer D Explanation AnswerDExp::Thyroidization of the kidney is a finding on renal biopsy that is commonly found in several chronic renal diseases. The process is characterized by renal tissue that resembles that of thyroid on renal biopsy under light microscopy.
Answer E AnswerE::Dilation of renal pelvis and calyces
Answer E Explanation AnswerEExp::Hydronephrosis is characterized by the dilation of renal pelvis and calyces. The patient’s presentation is not compatible with hydronephrosis.
Right Answer RightAnswer::A
Explanation [[Explanation::Bilateral renal cortical necrosis is a rare phenomenon caused by significantly diminished renal arterial perfusion secondary to vascular injury, spasm, or coagulopathy. Sepsis, disseminated intravascular coagulation (DIC), and pregnancy-related complications are typical inciting events for renal cortical necrosis. Other causes include drugs and blunt trauma. Contrast-enhanced computed tomography (CT) is the imaging of choice to diagnose renal cortical necrosis. CT scan reveals acutely hypo-dense areas in the renal cortex bilaterally with enhancement of subcapsular and juxtamedullary areas. Care should be taken with these patients as further injury from contrast media administration is possible. Chronic kidney disease develops up to 50% of patients requiring long term dialysis and transplantation. Partial recovery of renal function is a possibility in certain patients. The mortality rate from renal cortical necrosis exceeds 50% in untreated patients.

Educational Objective: Bilateral renal cortical necrosis is a rare complication of pregnancy-related medical conditions and sepsis. Contrast-enhanced CT scan is the imaging reveals bilateral renal infarcts that confirms the diagnosis.
References: Chervu I, Koss M, Campese VM. Bilateral renal cortical necrosis in two patients with Neisseria meningitidis sepsis. Am J Nephrol. 1991;11(5):411-5]]

Approved Approved::Yes
Keyword WBRKeyword::Renal, WBRKeyword::Renal cortical necrosis, WBRKeyword::Kidney, WBRKeyword::DIC, WBRKeyword::AKI, WBRKeyword::Acute kindye injury, WBRKeyword::Sepsis
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