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case records of the massachusetts general hospital

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Case 4-2013: A 50-Year-Old Man
with Acute Flank Pain
Anna Greka, M.D., Ph.D., R. Sacha Bhatia, M.D., Sharjeel H. Sabir, M.D.,
and John P. Dekker, M.D., Ph.D.

PR E SEN TAT ION OF C A SE

From the Departments of Medicine Dr. Emily A. Kendall (Medicine): A 50-year-old man was admitted to this hospital be-
(A.G., R.S.B.), Radiology (S.H.S.), and cause of acute pain in the left flank.
Pathology (J.P.D.), Massachusetts Gen-
eral Hospital; and the Departments of The patient had been well, with a history of Hodgkin’s lymphoma 15 years ear-
Medicine (A.G., R.S.B.), Radiology lier, until approximately 6 a.m. on the day of admission, when pain in the left flank
(S.H.S.), and Pathology (J.P.D.), Harvard occurred while he was bicycling. The pain was localized, without radiation, and
Medical School — both in Boston.
increased during the next 7 hours from 3 to 8 on a scale of 0 to 10, with 10 indicat-
This article was updated on June 6, 2013, ing the most severe pain. He came to the emergency department of this hospital.
at NEJM.org. At a routine annual visit 4 days before admission, the patient reported feeling
N Engl J Med 2013;368:466-72. well. Examination revealed nontender varicoceles and prostatic hypertrophy; the
DOI: 10.1056/NEJMcpc1201414 remainder of the examination was normal. A tetanus–diphtheria–pertussis vaccine
Copyright © 2013 Massachusetts Medical Society.
booster was administered. During the next 4 nights, he noted mild nausea and
temperatures to 38.1°C, without chills, which he attributed to the vaccination.
Fifteen years earlier, a diagnosis of Hodgkin’s lymphoma had been made, and the
patient had received six courses of doxorubicin, bleomycin, vinblastine, and dacar-
bazine, as well as radiation therapy and splenectomy; hypothyroidism had devel-
oped after treatment. He also had migraines, hyperlipidemia (type IIA), biapical
pulmonary fibrosis, and pulmonary sarcoidosis. A stress echocardiogram 21 months
before admission showed normal left ventricular function at rest, a mildly thickened
tricuspid aortic valve, mild aortic insufficiency, mild aortic-root dilatation, and
trivial regurgitation of the other valves; the stress echocardiogram was negative for
ischemia. Medications included calcium citrate, enteric-coated aspirin, simvastatin,
levothyroxine, and 25-hydroxyvitamin D (ergocalciferol), and he had received im-
munization against Haemophilus influenzae, pneumococcus, and meningococcus in
the past. He was married and worked in an office. He maintained a high-fiber,
low-fat diet, and he exercised, drank alcohol in moderation, and did not smoke. His
mother had had breast cancer, and she and a maternal aunt had had coronary
artery disease.
On examination, the patient was alert and oriented and appeared uncomfortable.
The temperature was 37.3°C, the blood pressure 158/72 mm Hg, the pulse 76 beats
per minute, the respiratory rate 20 breaths per minute, and the oxygen saturation
100% while he was breathing ambient air. A holosystolic soft murmur, grade 2/6,

466 n engl j med 368;5  nejm.org  january 31, 2013

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Copyright © 2013 Massachusetts Medical Society. Pyelonephri- sign was negative. grade 2/6. d-Dimer (ng/ml) <500 663 Diagnostic tests were performed. which were stable as compared with Neutrophils 40–70 76 previous studies. espe. Flank pain is were negative. 1). He was admitted to Basophils 0–3 1 the hospital. the hemoglobin with a diagnosis of pyelonephritis. Monocytes 4–11 8 Seven hours after presentation. hilar. Other test results are shown in most commonly related to renal disease. 2013 467 The New England Journal of Medicine Downloaded from nejm. CT Table 1. tis. performed according to a protocol Reference Range. the platelet count. with patent renal arteries and veins (Fig. however. and narcotic imaging findings do not support these diagnoses. dence that the pain began suddenly. White-cell count (per mm3) 4500–11. also was heard at the base. and urinalysis. is also an important consideration. albumin. a feature was aware of the precise moment that he started suggestive of gallstones. There was no evidence of fill- ing defects in the pulmonary arteries or of me. re. which may rhythm at a rate of 78 beats per minute. The fested as flank pain and hematuria. No other uses without permission. and mesenteric ischemia. renal function. Erythrocyte sedimentation rate 0–11 19 (mm/hr) DIFFER EN T I A L DI AGNOSIS C-reactive protein (mg/liter) <8. Laboratory Data. The fact that abdomen was nondistended.org by andria prima on June 8. and the normal level. 2016. For personal use only. having flank pain — that is. of the thorax. globulin. with normal bowel the urinalysis was normal would argue against a sounds and moderate tenderness to palpation in renal stone. for the assessment of pulmonary embolism. which would classically be mani- cially at the left upper sternal border.000 11. phosphorus. The remainder of the exami. total protein. or axillary lymphadenopathy. while riding his shaped defect in the left inferolateral kidney. case records of the massachusetts gener al hospital was heard at the apex. Cultures of blood and urine were ob. as were the hematocrit. In this case. contrast-enhanced abdominal and pelvic CT scan without guarding. * Reference values are affected by many variables. and a focal wedge.7 Lipoprotein A (mg/dl) <3 11 Dr. renal calculus. ondansetron. ential diagnosis of acute-onset flank pain must illa.400 monary nodules. as were the patient’s usual doses of levothyroxine and simvastatin. in the Differential count (%) right lung. and liver function infection of the kidney unlikely. though the patient did indeed present with fever. tion and the laboratory methods used. amylase. for all patients. tests of urinalysis without evidence of pyuria makes an coagulation. and lipase were nor. Renal ischemia is characterized by the acute on- Computed tomography (CT) of the abdomen set of pain. Table 1. Al- lytes. All rights reserved. which classically presents with flank pain nation was normal. intraabdominal processes such as cholecystitis. calcium. An electrocardiogram showed sinus pancreatitis. They may therefore not be appropriate precise time of the onset of pain. and fever. with cause referred pain to the flank. should be ruled probable left ventricular hypertrophy. tained.8°C. and a crescendo–decrescendo systolic mur. glucose. the physical examination and Intravenous fluids. Lymphocytes 22–44 14 diastinal. the patient’s Eosinophils 0–8 1 temperature rose to 37. which is evi. It is important that this patient hyperdense material in the gallbladder.0 59. analgesia were administered. out. Patients with renal ischemia are able and pelvis after the administration of oral and to describe the exact time of onset of the pain intravenous contrast material showed layered and its severity. The ranges used at Massachusetts The patient provided specific details about the General Hospital are for adults who are not pregnant and do not have medical conditions that could affect the results. The differ- n engl j med 368. Examination for Murphy’s is needed to rule out this diagnosis. Variable Adults* On Admission vealed bilateral posteromedial fibrosis and pul.5  nejm. the abrupt onset of flank pain is not well matched mal. Ischemia There was symptomatic improvement. including the patient popula- ma presented with the acute onset of flank pain. begin with a consideration of renal colic due to a mur. but definitive imaging with a non– the left flank below the costophrenic angle.org  january 31. 2 to 3 mm in diameter. . Anna Greka: This generally healthy 50-year-old man with a remote history of Hodgkin’s lympho. with radiation to the ax. The blood levels of electro.

org  january 31. tumor embolus in the kidney or thromboembo- in situ thrombosis of the renal artery. This symptom is most consistent with renal alarm in this patient because he does not have a infarction. this appearance is consistent with infarction. or aneu. 3 mm in diameter. therefore. Fever in an asplenic patient carries a acute onset of severe pain. No other uses without permission. Sabir: CT of the abdomen and vasculitis (specifically.5  nejm. In addition. both left and right pulmonary arteries are free from any filling defects. fever.6 CT of the lism related to the hypercoagulable state that abdomen and pelvis with the administration of accompanies many malignant tumors should be intravenous contrast material is the test of choice considered. toms. Dr. A low-grade fever is. this nodule meets the CT criteria for a benign process such as a noncalcified granuloma. is shows bilaterally symmetric paramediastinal sub. . For personal use only. volume loss. the patient’s history of can- to assess renal infarction. The n e w e ng l a n d j o u r na l of m e dic i n e pleural reticular opacities in the upper lobes. 1) shows a wedge. is visualized in the right middle lobe. it is worth briefly diagnosis of either a thromboembolic event due to considering alternative causes. the normal urinalysis. Of note. architectural distortion. not worrisome. specific differential diagnosis that is central to the development of hypertension in an otherwise the understanding of this case.2 The spleen. centrally important for the production of opso- 468 n engl j med 368. and renal infarc- shaped hypodense region. left kidney. There is no other acute intraabdominal lating bacteria. in itself. with relatively straight margins. with fever. Sharjeel H.1. although the condition is rare. this patient received oral contrast material shows a wedge-shaped hypo­ dense region (arrow) involving the lower pole of the a scheduled vaccination (tetanus–diphtheria– left kidney. stenosis. What could cause the renal infarct? A coronal reformatted image from CT of the abdomen During a routine visit to his doctor’s office just and pelvis after the administration of intravenous and 4 days before presentation. half of the total B lymphocytes responsible for A pulmonary-vessel CT angiogram (CTA) immunoglobulin production and. pertussis). polyarteritis nodosa. and the presence of fever support the infarct associated with fever.org by andria prima on June 8. cer is remote. a feature consistent with infarction. Cancer causing a clots in the heart or the aorta4. and there is no other evidence sup- May we see the imaging studies? porting this diagnosis. Finally. without evidence of The sinusoids of the spleen filter blood and allow atherosclerotic calcification. 2013 The New England Journal of Medicine Downloaded from nejm. All rights reserved. or at least temporally correlated. which was associated. Fever in the asplenic patient the renal vessels are normal.5 or. can present with pain. A solid subpleural pulmonary nodule. pyelonephritis. although there is little else in this case to renal medulla. Copyright © 2013 Massachusetts Medical Society. 2016. and trac- tion bronchiolectasis. involving the lower pole of the support this diagnosis. with its apex at the tion. There is no mediastinal or hilar lymphadenopathy. However. patients with Dr. resident mononuclear phagocytes to ingest circu- rysm. and an intraab- dominal process can be ruled out because the images point to a renal infarct as the most likely underlying cause of the patient’s symp- Figure 1. features that are consistent with pul- monary fibrosis due to previous radiation. Because it has been stable since it was observed on CT of the chest 2 years earlier. a pelvis after the administration of intravenous and medium-vessel vasculitis affecting the kidney) oral contrast material (Fig. more rarely. CT of the Abdomen and Pelvis.7 The spleen also contains nearly process. Given the clinical presentation. Greka: The imaging studies in this case are helpful in narrowing our differential diagnosis. Before devoting normotensive patient (indicating an acute kidney our attention to the presumed cause of a renal insult3). A renal calculus. but it does cause bike.

this patient had received im. inent leukocytosis led us away from a diagnosis including Streptococcus pneumoniae. normal renal from the circulation by the spleen. such as Capnocytophaga scopic hematuria or even proteinuria. which is in New England and spent time outdoors. we have no evidence that An important feature of this case was the presence this situation occurred in this case. more than 50% of the cess.18 Segmental arterial mediolysis. case records of the massachusetts gener al hospital nizing antibodies.org by andria prima on June 8. and micro- less common pathogens.5. signs of extrarenal embolization14 (e. on tion. although canimorsus. However. Renal Infarction munizations against these organisms in the past.14 The most associated with bacteremia and endocarditis in common cause of renal infarction (Table 2) is asplenic patients and other immunocompro. an important consideration in this case. brillation. or thromboemboli sites that infect red cells. this patient resided vegetations from infective endocarditis.16 ed that further investigation of these clinical signs To synthesize all these findings into a final by echocardiography was indicated.18-20 which in a young patient with medial fi- most consistent with aortic stenosis.3 as in this Centers for Disease Control and Prevention case. For personal use only.14 In situ of heart murmurs. farction was strongly suggestive of an infectious The most parsimonious explanation for the com- process. new heart murmurs. and a holo.6. Renal infarcts usually present with the abrupt in accordance with the recommendations of the onset of abdominal or flank pain. left ventricular thrombus in a patient our patient may also have been at risk for para. and a wedge-shaped n engl j med 368. it is most often due before presentation showed that the patient had to renal-artery occlusion from an aortic dissec- mild insufficiency of all valves. All rights reserved. 2016. . I shall invoke the principle that the ence of fever.. since derived from ruptured plaque in the aorta.6.2.5  nejm. to S.g. pneumoniae.9 and Bordetella holmesii. and a normal hematocrit with a mildly mon causes of sepsis in asplenic patients relate to elevated white-cell count.org  january 31. cytosis. H. may also cause renal infarction. a fulminant and often rapidly fatal illness was also helpful in this case. which is emboli or bilateral disease. a feature that is sia.12 deep venous thrombosis in a patient with a pat- ent foramen ovale may also result in emboli to Endocarditis the kidney.1. a condition cases of sepsis and associated deaths are related that may be associated with renal infarction.7 Therefore.6. Tumor fore. such as babesia.1. a feature that is most consistent with rare. drop in the hematocrit. The most com. with a specific concern for endocarditis bination of fever. which were not seen in this case. and sometimes they are associated with (www.5.7 Presumably. an elevated creatinine level.gov. although the axilla. broplasia could appear on angiography as a renal systolic murmur was detected that radiated to infarct.2. murmurs. No other uses without permission. with myocardial infarction. and to some ex- tent reassuringly.11. recommendations of the ACIP [Ad. The pres. and renal in. diagnosis. Since this patient was a bicyclist and spent time Renal infarction is often associated with leuko- outdoors.cdc. they suggest. one should be concerned about babesiosis or fat emboli or a paradoxical embolus from a as the underlying cause of his presentation. it is also reasonable to consider other.15-17 decrescendo murmur was detected that radiated Another consideration is fibromuscular dyspla- to the left upper sternal border.1. The patient had resulting from infections that are normally cleared normal blood chemical profiles. function.8 Appropriately. There. However. Although it was not clear usually a sudden manifestation associated with a whether these murmurs were new. influenzae. simplest answer is most likely the correct one. logic deficits). An echocardiogram 21 months thrombosis can also occur. 2013 469 The New England Journal of Medicine Downloaded from nejm. thromboembolic disease from the heart or aorta mised hosts. such as subacute endocarditis.10 Although bacteria are by far the due to a left atrial clot in a patient with atrial fi- most common pathogens in asplenic persons. Copyright © 2013 Massachusetts Medical Society.7 This function is critical in the with valvular vegetations13 and an associated clearance of encapsulated organisms.14 the spleen removes senescent erythrocytes from Other sources of thromboemboli can be valvular the circulation. The absence of a prom- bacterial infection with encapsulated organisms. of sepsis and toward a subacute infectious pro- and Neisseria meningitidis. a pathogen associated with dog bites these findings are most consistent with large or dog scratches. a possibly new crescendo– aortic or a renal endovascular intervention.2. an asplenic patient is at risk for postsplenectomy Careful analysis of available laboratory data sepsis. thromboembolic event affecting the kidney.5. but it is mitral regurgitation. but it can be a complication after either an physical examination. neuro- visory Committee on Immunization Practices]).

NEJM. noncoronary cusp of the aortic valve (Panel A. The other valves did not have vegetations. appendage and no aortic atheroma. No other uses without permission. including no clot in the left atrial lar leak (Panel B). Kendall. There was no evidence of other sources of car- without evidence of an aortic-root abscess or paravalvu. 2016. There was mild-to-moderate aortic insufficiency. Al- Thromboembolic causes.org by andria prima on June 8.org). An echogenic mass was seen on the noncoronary cusp of the aortic valve. All rights reserved. with an ejection fraction of 60%. possibly related to a dilated cardiomy- opathy caused by previous chemotherapy.5 nejm. Sacha Bhatia: A transthoracic echocardio- gram was obtained. a finding that is consistent with vegetations (Fig. No intracar- diac shunt was seen. Transesophageal echocardiography was per- formed. A NNA GR EK A’S DI AGNOSIS Thromboembolic renal infarction due to endo- carditis in an asplenic patient. Rosenberg: Dr. including an atrial thrombus in this A patient with atrial fibrillation. or a ventricular source.org january 31. The n e w e ng l a n d j o u r na l of m e dic i n e renal infarct in an asplenic patient is thrombo- Table 2. There was no evidence of an aortic-root are available at A transesophageal echocardiogram at the midesoph. Segmental arterial mediolysis what was your clinical impression when you saw Polyarteritis nodosa this patient? Complication of the antiphospholipid syndrome Dr. Dr. shows vegetation on the 2B). 470 n engl j med 368. embolic renal infarction due to endocarditis. 2A. long-axis view. We also considered thromboembolic sources in the heart. The other valves appeared normal. diac embolus. abscess or a mycotic aneurysm in the aorta (Fig. Causes of Renal Infarction. One can- not say definitively that there were vegetations on the aortic valve. DR . and Videos 1 and 2. may we see the echo- cardiogram? B Dr. Rosenberg (Pathology): Dr. This echogenic mass transesophageal was associated with moderate aortic insuffi- echocardiography Figure 2. The left ventricular systolic function was normal.org ageal level. R. Echocardiographic Images. ciency. arrow). which showed thickening of multiple aortic leaflets but no stenosis. Fibromuscular dysplasia Dr. a transthoracic Renal-artery occlusion from aortic dissection or transesophageal echocardiogram to look for valvular vegetations would be helpful in making Spontaneous or iatrogenic renal-artery dissection the diagnosis of endocarditis. 2013 The New England Journal of Medicine Downloaded from nejm. centrally directed aortic insufficiency. Copyright © 2013 Massachusetts Medical Society. CL INIC A L DI AGNOSIS Endocarditis complicated by an embolic event in the kidney. Kendall: Identifying the heart murmurs on Cocaine use examination led us to think about endocarditis complicated by an embolic event to the kidney. Bhatia. available with the full text of Videos showing this article at NEJM. from the heart or aorta though blood cultures may ultimately identify the In situ thrombosis causative organism in this case. . For personal use only. Eric S. There is moderate.

in conjunction with stenosis. case records of the massachusetts gener al hospital PATHOL O GIC A L DISCUSSION Dr. I suspect the clinicians heard a Dr. mutans.21 Streptococcal species (in.org. For personal use only. John P.and methicillin-resistant Staphylococcus aureus bac- mycin for the MRSA bacteremia. We thank Dr. n engl j med 368. All subsequent blood cultures were diac murmurs. Dekker: Two sets of blood cultures were received by the microbiology laboratory on the day of admission. the organism was identified as S. and S. The Disclosure forms provided by the authors are available with patient is now doing well. Mary Etta King for assisting with review of the Dr. One was consistent with aortic lar source of infection and. mutans.systolic-flow murmur due to increased cardiac coccal endocarditis and bacteremia with penicil. For Streptococcus mutans bacteremia and endocarditis the first 2 weeks. could have been better heard by listening to the heart sounds while the patient was sitting for- FOL L OW-UP ward at end expiration or by performing a hand- grip maneuver.13 In total. . Lloyd Axelrod (Medicine): What can we learn echocardiograms. which is often a very noisy place. Kendall: The patient was treated for strepto. No potential conflict of interest relevant to this article was re- later showed a persistent mobile density on the ported. He completed a 4-week course of ceftriaxone. On the fourth hospital day. We then switched his antibacterial therapy to ceftriaxone.org  january 31. Copyright © 2013 Massachusetts Medical Society. the full text of this article at NEJM. Hasan Bazari. To appreciate such a mur- culture also grew methicillin-resistant Staphylo.output secondary to fever and tachycardia. Figure 3. The high-grade nature of ultrasound study? The patient was said to have the bacteremia was suggestive of an endovascu. cluding S. one bottle from the initial set turned positive. 15 are present. if cardiac coccus aureus (MRSA). of which 11 out of the first 14 bottles grew S. transthoracic echocardiogram obtained 3 months This case was presented at the Medical Case Conference. makes a huge difference. mutans) are the most common cause of A representative image from another case shows a native-valve endocarditis in adult patients. Viridans group streptococci are common commensal components of the hu- man oropharyngeal flora. aortic valve. Chains of gram-positive cocci and coccobacillary forms counting for 45 to 65% of cases. although it appeared improved. In diastolic murmur is almost always pathological addition to growing S. Gram’s stain prepared from a positive blood culture. and the other was more consistent with the clinical and echocardiographic findings. mutans. 2013 471 The New England Journal of Medicine Downloaded from nejm. about the physical examination from the cardiac and Lloyd Axelrod for the organization of the conference. Bhatia: I suspect the clinical environment embolism to the kidney. was mitral regurgitation.5  nejm. he was also treated with vanco. Microbiology. A follow-up teremia. lin while in the hospital. It was presumed that the disease is suspected. and a Gram’s stain showed chains of gram-positive cocci similar to those shown in Figure 3.) sets of blood cultures were obtained during the hospital course.org by andria prima on June 8. a member of the viridans group streptococci. After culture on a blood agar plate. ac. the clinicians should per- MRSA infection was acquired during the hospi. The initial cardiac ex- The final blood culture that became positive amination was performed in the emergency de- was received on the fifth hospital day and was partment. (Photograph courtesy of Judith Holden. and Drs. consistent with bacterial endocarditis and septic Dr. mur. two murmurs. A reported positive on the seventh hospital day. 2016. this final positive and may be subtle. form maneuvers that may accentuate certain car- tal admission. it is best to be in a quiet room. In this case. aortic regurgitation negative. No other uses without permission. mutans has been identified as a major contributor to tooth decay and dental caries. All rights reserved. which is A NAT OMIC A L DI AGNOSIS easier to administer on an outpatient basis. David Dudzinski.

Coburn JW. travascular clearance after splenectomy.300:183-5. Bishop MC.93:457-8. patients with segmental renal infarction. 2016. 15. Krause PJ. Radiographic. Renal artery embolism: clini. Balshi JD. 2001. Every year 40 sets are produced. and cardiac studies.81:890-4. et al. Streptococ- Chu TS. Mylonakis E. Department of Pathology. J Hum Hypertens 2006. or individual sets may be purchased for $50 each. BMJ 1990. Gregson RH. Miller PD. which began in January. This slide set contains all of the images from the CPC. Medicine (Baltimore) 2004. Renal arterial fibro- infarction and hypertension. tern Med 1980. Shepard CW. dence of medial fibroplasia. Ann Intern Med 1978. as well as unpublished text slides. Le Coz 10. and diagrams. Stinch- 5. et al. Hosea SW. J Hypertens asplenic patients. Ann In. pelvic. Blood pressure and RM. neurologic. S. averaging 50-60 slides per set. Manhire AR.11:336-40. 10th ed. muscular dysplasia: acute renal infarction 2006. Paris B. Spellerberg B. MC. Plouin PF. Clinical characteristics of 14.20: 2.5  nejm. combe SJ.161:272-6.. are included. In: Versalovic J. renal. Weger N. The cost of an annual subscription is $600. Acute 11. Clin Infect 20. Manhire AR. Stawicki SP. pain. Postsplenectomy sepsis and its mortal. Surg 1991. Br J artery dissection: three cases and clinical (Baltimore) 1999.345:1318-30. Hill D. et al. Daneshvar MI.46:370-6. Lantern Slides Updated: Complete PowerPoint Slide Sets from the Clinicopathological Conferences Any reader of the Journal who uses the Case Records of the Massachusetts General Hospital as a teaching exercise or reference material is now eligible to receive a complete set of PowerPoint slides. algorithms. Stinchcombe SJ. Clin Infect Dis 2004. Medicine ity rate: actual versus perceived risks. Traumatic renal artery thrombosis. Kaufman JJ. Bishop renal outcomes in patients with kidney a newly recognized clinical entity among MC. Zarrabi MH. Mansmann U. For personal use only. Infec.24:1649-54. Fibromuscular dyspla- with a diagnosis of atrial fibrillation.304:245-50. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. Am J 19. Krauss M. Engholm G. Husted S. Johnsen S. Huang JW. Washington. Cosby RL. Martone WJ.89:477-82. Application forms for the current subscription year.3:631-5. DC: ASM Press. 472 n engl j med 368. Wei YF. MA 02114 (telephone 617-726-2974) or e-mail Pathphotoslides@partners. Kaiser J Endovasc Ther 2003. Holdsworth RJ. Am J N Engl J Med 1981. not only those published in the Journal.76:696-701. in three patients with angiographic evi- 4. Stinchcombe SJ. 17 cases. et renal infarction in patients with atrial fi. Gregson RH. 21. and extremity munocompromised patients. Spontaneous renal characteristics of 17 patients. dysplasia of renal arteries and acute loin thromboembolism in the aorta and the Persistent and relapsing babesiosis in im. 2011:331-49. Azzam ZS. infrarenal versus suprarenal fixation. Massachusetts General Hospital. Bordetella holmesii bacteremia: 18. shown at the live Clinicopathological Conference (CPC) that is the basis of the Case Record. mesenteric. Manual of clinical microbiolo- Nephrology (Carlton) 2006. Nasser NJ. Hamburger MI. Paulis M. Böckler D.org. Gregson RH. 13. M. Acute renal infarction: clinical A. Hazanov N. Postsplenectomy sepsis with 17. Frank MM. et al. Carroll KC. Nikfardjam 8. Bishop arteries after discharge from the hospital Dis 2008. case records of the massachusetts gener al hospital References 1. eds. Copyright © 2013 Massachusetts Medical Society.300:817. Gewurz BE. Bobrie G. Cuschieri 16. 3. Chedid A. Funke G. Chen SI. may be obtained from the Lantern Slides Service. Attali M.org  january 31.10:1054-60. cal features and long-term follow-up of gy.78:1031-8. Br J Radiol renal infarction from a cardiac thrombus. Incident 12. Calderwood SB.83: organism from the patient’s dog. Møller Med 1984. Rosenfeld JC. Acute renal embolism: forty-four cases of Scheld WM. gross specimens. Med 1986. Babesiosis in splenectomized 1992. dovascular AAA repair: relationship to 292-9. and photomicrographs. Fields EL. Opsonic requirements for in. sia of renal arteries: a neglected cause of Arch Intern Med 2001. Domanovits H. Nat Clin Pract Nephrol 2007. Brown EJ. Henneberg EW. Brandt C. Abadi S. Rosner F. et al. . 710-8. Rossignol P. Schrier RW. Somin M. tive endocarditis in adults. Each set is supplied on a compact disc and is mailed to coincide with the publication of the Case Record. Lessman RK. Boston. N Engl J Med acute loin pain. Johnson SF. cus. 9.65:81-4.78:386-94. with identifying legends. including digital images. Benach JL. adults: review of 22 reported cases. 2013 The New England Journal of Medicine Downloaded from nejm. 7. DF-2: report of a case with isolation of the al. All rights reserved. Minson GE. BMJ 1990. Manhire AR. 6. Zuehl RW. Chu PL.org by andria prima on June 8. Habicht GS. Wu KD. Irving AD. tables. Incidence of renal infarctions after en- brillation. 38:799-804. Fibromuscular H. Frost L.