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+A 43-year-old man was admitted to the emergency department due to sudden left lumbar pain, continuous and incapacitating, without antalgic position or aggravating factors, without irradiation, with approximately 23 hours of evolution. No nausea or vomiting, no macroscopic haematuria or lower urinary tract discomfort. Absence of precordial pain. Hypertension controlled with verapamil. He reported an episode, interpreted as a transient ischaemic attack, approximately eight weeks earlier (not confirmed). No history of cardiac arrhythmia or valvular heart disease. No other previous thromboembolic episodes. No known history of urinary lithiasis. No osteoarticular or respiratory complaints. No cocaine abuse. No history of hepatitis B or C. Medicated with 160 mg/day of verapamil.
+Physical examination showed diaphoretic, BP 150 / 110 mmHg, 80 beats per minute, rhythmic and wide. Temperature 37.8 ºC. Abdomen painful on deep palpation in the left iliac fossa and flank, with defence, with no signs of peritoneal irritation. Decreased RHA. No abdominal murmurs. Negative bilateral renal Murphy. Existence of symmetrical arterial pulses. No perfusion deficit in the extremities. General neurological examination without alterations.
+Renal ultrasound showed no abnormalities, especially dilatation of the urinary tract. Laboratory tests: Hb15.6 g/dL, Leuc 13,800/µL, Neut 76.1%, Creat 1.4 mg/dL, TGO 104 UI/L, TGP 74 UI/L, LDH 1,890 UI/L. Coagulation parameters showed no alterations. The ECG showed sinus rhythm, with no alterations compatible with acute myocardial ischaemia. An abdominal and pelvic CT scan was requested, which showed the presence of multiple areas without contrast uptake in the left kidney, without morpho-structural alterations, compatible with multifocal areas of ischaemia, with multisegmental distribution, probably of embolic aetiology. No aortic dilatation or renal artery aneurysm. No intra-peritoneal alterations. Taking into account the multi-segmental distribution of the ischaemic process and the duration of discomfort, we decided that there was no indication for invasive manoeuvres. The patient underwent systemic hypo-coagulation with heparin in an attempt to avoid future embolic episodes and appropriate analgesia.
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+He then underwent multiple examinations in an attempt to identify an embolic focus and the aetiological process. Echocardiography ruled out pathology of the cardiac valvular apparatus or the existence of valvular vegetations. Absence of areas of myocardial dyskinesia. Arteriography showed a perfusion deficit of the lower pole of the left kidney with multiple other less prominent areas showing perfusion deficits as well. No other alterations such as macro/microaneurysms or alterations of the main renal artery or aorta were detected.
+The study to rule out prothrombotic and vascular disease (lupus anticoagulant, anti-cardiolipin, ANCA's, detection of cryoglobulins, ANA's, determination of immunoglobulins and complement fractions) was negative.
+After 15 months of follow-up, we were left without an aetiological diagnosis. The patient remains asymptomatic, with no new episodes of embolism or manifestations of systemic disease. Anti-coagulation therapy has been discontinued. He maintains controlled hypertension with the same dose of verapamil. The last analytical control had a serum creatinine of 1.2 mg/dL, and GFR of 93 ml/min. The follow-up kinillogram shows a functional deficit of the affected renal unit (differential function 41%).
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