After a Wild Party, a 24-Year-Old Has Intense Abdominal Pain

Marie-Lee Simard, MD; Alexandre Lafleur, MD, MSc

Disclosures

July 08, 2021

In this case, the vascular surgery team was consulted and the patient was immediately treated with a bolus followed by a perfusion of intravenous heparin. Because of the rapid improvement in renal function with anticoagulation and the symptom duration of more than 24 hours, the surgeons decided not to use endovascular approaches to treat this patient's partial thrombosis of the main renal artery. Transthoracic and transesophageal echocardiograms showed no vegetation, thrombus, or myxoma. Repeated blood cultures were negative. The results of an extensive workup, which included prolonged ambulatory cardiac monitoring, hypercoagulable state studies, and genetic testing for Marfan and Ehlers-Danlos syndromes, were normal. The aorta appeared normal on a CTA. No signs of fibromuscular dysplasia were found on the renal arteries (eg, a "string of beads" pattern). A follow-up CTA 1 year after the event showed a normal right main renal artery.

The patient was discharged on warfarin therapy. He had minimal residual pain, and his mild hypertension was treated with amlodipine. Upon follow-up at 3 months, his renal function continued to improve (eGFR of 81 mL/min/1.73 m2). His proteinuria and hypertension had both resolved. Warfarin was switched to apixaban. Six months after the diagnosis, anticoagulation was stopped and replaced with low-dose oral aspirin (80 mg daily), with no evidence of recurrence at 2 years. The patient refrained from using cocaine.

In the absence of an alternative cause after extensive workup, intranasal cocaine consumption is thought to have provoked this patient's in situ renal artery thrombosis. Although rare, cocaine-associated renal infarct has been described in at least 16 case reports.[21] Most patients are men younger than 40 years who present with unilateral renal infarct and report intranasal or intravenous cocaine use a few days earlier.[21] Multiple mechanisms have been postulated, including renal vasoconstriction that results from the blockade of noradrenaline reuptake or adrenergic stimulation, endothelial dysfunction, and prothrombotic states.[22] Subsequent cocaine use is a risk factor for recurrence and should be avoided completely.

In conclusion, renal infarction often mimics nephrolithiasis and pyelonephritis. Therefore, a CT scan of the abdomen and pelvis without contrast is commonly performed initially and will be normal. In the setting of acute flank or abdominal pain with high LDH levels and little or no rise in serum aminotransferase values, clinicians should consider the diagnosis of renal infarction and obtain a contrast-enhanced CT scan.

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