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

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⇓).