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A case of loin pain: a cause close to the heart

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6644 (Published 16 October 2012) Cite this as: BMJ 2012;345:e6644
  1. T J Cahill, academic clinical fellow1,
  2. K Nagaratnam, specialist registrar1,
  3. R Browning, specialist registrar2,
  4. S Anthony, consultant radiologist2,
  5. J Dwight, consultant physician and cardiologist1
  1. 1Acute General Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK
  2. 2Department of Radiology, John Radcliffe Hospital
  1. Correspondence to: T J Cahill thomas.cahill{at}cardiov.ox.ac.uk

A 44 year old man with type 2 diabetes presented with sudden onset severe pain in the left loin, which was associated with several episodes of vomiting. Although he reported exertional chest discomfort in the preceding year, he had not experienced chest pain or breathlessness in the weeks leading up to the admission. On examination, he was normotensive, with a heart rate of 80 beats/min and an oxygen saturation of 98% on air. He was tender in the left renal angle, but the rest of his clinical examination was unremarkable. Electrocardiography showed deep anterior T wave inversion. Laboratory tests showed a raised white cell count (13.9×109/L; reference range 4-11), C reactive protein (65.1 mg/L; <10mg/L; 1 mg/L=9.52 nmol/L), and troponin I (0.29 µg/L; <0.05). Renal and liver function tests were within normal limits. A clinical diagnosis was confirmed by imaging, shown below (fig 1).


  • 1 What type of imaging was used and what were the findings?

  • 2 What is the next most appropriate investigation?

  • 3 What are the causes of intracardiac thrombosis?

  • 4 What is the unifying diagnosis?

  • 5 How can this condition be managed?


1 What type of imaging was used and what were the findings?

Short answer

This is an arterial phase contrast enhanced computed tomogram of the abdomen. Contrast is absent beyond the proximal segment of the left renal artery, with non-enhancement of the left kidney. A wedge shaped area of non-enhancement is also seen in the right kidney, consistent with a renal infarct. The findings are consistent with bilateral …

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