A 21-year-old man admitted with shock due to severe pelvic fracture after a motorcycle accident was found in contrastenhanced computed tomography (CT) to have no renal visualization except for the upper pole of the right kidney and only part of the left kidney. Aortography showed complete occlusion of the right renal artery and a circumferential intimal defect of the left renal artery. Fearing that surgical exploration would increase retroperitoneal hemorrhage, we conducted percutaneous transluminal angioplasty (PTA) and placed a Palmaz stent in the left main renal artery 18 hours after injury, after which urine output progressively increased. Hemodialysis was needed until hospital day 29, after which renal function gradually improved. Repeated renal scintigraphy was useful in determining renal function. On hospital day 160, aortography showed the left main renal artery to be patent and stenosis-free. The man was discharged on hospital day 165. Traumatic bilateral renal arterial occlusion is rare, with only 21 cases reviewed in the literature. Early diagnosis and treatment are essential to avoid permanent by impaired renal function. We found that PTA is a viable alternative to surgical revascuralization, especially in patients who are hypotensive without a need for surgical exploration for further abdominal injury.
A 70-year-old man admitted for right back pain and vomiting had mild tenderness and rebound pain in the right upper abdomen. Abdominal radiography and computed tomography (CT) couldnot differentiate the ruptured gallbladder from the dilated transverse colon. Abdominal magnetic resonance imaging (MRI) showed gas and fluid in the ruptured enlarged gallbladder and detected the shrunken transverse colon beneath the dilated gallbladder. He had long taken warfarin potassium for pulmonary embolism and his PT-INR was 8.98. After administration of vitamin K2, we undertook emergency surgery for the ruptured distended gallbladder. Massive old blood and clots filled the abdomen. Several gallbladder stones dropped in the Morison pouch. Klebsiella pneumoniae and Clostridium perfringens were found in the ascites culture. We diagnosed him as having perforated emphysematous cholecystitis which tended to coexist with diabetes mellitus and infection caused by aerobic and anaerobic pathogenes. The gallbladder rupture was possibly caused by wall ischemia due to arterial sclerosis and dilation caused by massive blood and clots in the gallbladder. After surgery, he was controlled with mechanical ventilation in the intensive care unit. No serious event occurred postoperatively except for mild pneumonia.
We present a case of fulminant systemic lupus erythematosus (SLE) associated with thrombotic thrombocytopenic purpura (TTP) involving multiple organ failure. A 28-year-old woman diagnosed with SLE and treated with prednisolone for 6 months suddenly underwent severe heart failure and loss of consciousness. Laboratory tests showed severe anemia, thrombocytopenia, renal failure, and liver dysfunction. An extensive series of imaging examinations showed cerebral infarction, myocarditis, splenic infarction, and cystitis. Severe bleeding tendency caused hemorrhagic ascitis, hemorrhagic pleural effusion, hematuria, and systemic subcutaneous hemorrhage, and her general condition deteriorated. The patient was diagnosed with fulminant SLE associated with TTP and received intensive care including continuous hemodialysis, mechanical ventilation, and massive transfusion. One course of high-dose intravenous methylprednisolone and 5 series of plasma exchange (PE) suppressed SLE activity, and her general condition and consciousness gradually recovered. Thrombocytopenia was not controlled by these therapies. After using antiplatelet drugs, platelet count elevated dramatically. TTP is an unusual complication of SLE, and the treatment for fulminant SLE associated with TTP is not well known. In our case, combined treatment with PE, methylprednisolone, and antiplatelet drugs was effective for recovery.