Endgames Picture Quiz

A case of progressive bilateral pitting oedema

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3 (Published 20 January 2015) Cite this as: BMJ 2015;350:h3
  1. Fatima Alves Pereira, foundation year 1 doctor1,
  2. Matthew Di Capite, foundation year 1 doctor2,
  3. David Thompson, consultant interventional radiologist3,
  4. Matt Hayes, consultant urologist 4,
  5. Kate Akester, consultant in acute and general medicine5
  1. 1Department of Acute Medicine, Southampton General Hospital, Southampton, UK
  2. 2Department of General Surgery, Southampton General Hospital, Southampton, UK
  3. 3Department of Radiology, Southampton General Hospital, Southampton, UK
  4. 4Department of Urology, Southampton General Hospital, Southampton, UK
  5. 5Department of Acute Medicine, Southampton General Hospital, Southampton, UK
  1. Correspondence to: F Alves Pereira fda22{at}cantab.net

A 68 year old man presented with a two month history of progressive shortness of breath. He had previously been able to swim three times a week, but was now becoming short of breath on climbing stairs. His associated symptoms included orthopnoea, swollen ankles, weight gain, and anorexia. He was being treated with simvastatin for hypercholesterolaemia and diltiazem for hypertension and had never smoked.

On examination, he was plethoric, his pulse was regular at 84 beats/min, and his blood pressure was 138/72 mm Hg. Heart sounds were normal and his jugular venous pressure was not raised, although he had pitting oedema to the mid thighs. Findings on respiratory examination included a respiratory rate of 20 breaths/min, with dullness to percussion and associated reduced breath sounds over the right lung base. His abdominal examination was unremarkable.

Laboratory tests showed haemoglobin 129 g/L (reference range 130-170), mean cell volume 79.4 fL (80-100), and creatinine 127 μmol/L (80-115). All other blood test results, and an electrocardiogram, were unremarkable. Chest radiography showed mild cardiomegaly and echocardiography showed well preserved left ventricular size and function. As a result, computed tomography with contrast of his chest, abdomen, and pelvis was performed (figure).

Reformatted curved coronal section through the abdomen

Questions

  • 1. What abnormalities can be seen on the computed tomogram?

  • 2. How does the condition labelled A present?

  • 3. How would you classify the lesions labelled A?

  • 4. How would you manage this condition?

Answers

1. What abnormalities can be seen on the computed tomogram?

Short answer

The computed tomogram shows a small renal mass in the right kidney (A) and a large filling defect within a grossly dilated suprarenal inferior vena cava (B).

Long answer

The computed tomogram shows a small renal mass in the right kidney that probably represents a renal cell carcinoma (RCC), and a grossly dilated suprarenal inferior vena cava containing a large heterogeneous mass (tumour thrombus) …

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