Introduction and Background
A 58-year-old female presented with sudden sharp right sided flank pain, associated with vomiting. The symptoms improved with analgesics. She had a similar episode the next day with acute left sided flank pain. She had no other associated symptoms. Her medical history was significant only for migraines and palpitations for which she takes Zomig and Propranolol respectively. CT Scan imaging was suggestive of bilateral renal infarcts with some narrowing and irregularity along the anterior branch of right renal artery and the distal aspect of posterior branch after bifurcation of the left renal artery. An echocardiogram was normal.
How does a relatively young healthy person suddenly develop bilateral renal infarcts?
The three possibilities arising from the Discussion were 1) a hypercoagulable state 2) spontaneous dissection, and 3) a large vessel vasculitis. While a cardiac embolic cause was not completely ruled out by the normal echocardiogram, it was not considered further.
The discussants shared their clinical experiences and treatment of cases of spontaneous dissection with fibromuscular dysplasia as well as Ehlers Danlos (vascular type) and segmental arterial mediolysis. An interesting case of a patient presenting with renal infarction with history pertinent only for heavy marijuana use and negative workup led another discussant to this article: “Acute renal infarction and heavy marijuana smoking”.
Other articles shared included renal infarction associated with:
Then, one astute discussant focused on the medical history and shared articles linking the use of triptans (migraine drugs used for their vasoconstrictive effects) and renal ischemic events:
The hypercoagulability work up and imaging studies were negative for this patient; the angiography showed a single tight lesion in branch of renal artery on right side, that was stented. On left side, other than some irregularity, no lesion was found. There was no evidence of dissection. Based on the otherwise negative findings and the case reports of renal infarction associated with zolmitriptan (Zomig), the discussants concluded that the drug is likely responsible in this case.
Bilateral renal infarction is a rare diagnosis. Even after extensive hypercoagulability work up and imaging studies often a cause is not found. This case and discussion provides us with reasons to suspect drugs like marijuana and triptans in cases of renal infarction, and reminds us the importance of the medical history.
Read the full discussion here.