A 76 year-old man transferred to The Johns Hopkins Hospital with a 3-month history of worsening fatigue and shortness of breath.

The patient is a 76-year-old Caucasian man who presented to his primary care physician complaining of three months of increasing dyspnea and fatigue. He reported initially mild dyspnea on exertion that progressed to shortness of breath at rest. Recently he noted becoming lightheaded when trying to climb stairs. He had occasional cough, but denied hemoptysis or purulent sputum. He had not had any loss of consciousness, chest pain, or palpitations. He did complain of orthopnea and required two pillows to sleep. Over the past one month prior to admission he also noticed worsening swelling of his feet and ankles, most notable at the end of the day. There was also frequent numbness and tingling in his feet and ankles. He reported approximately 40 lbs weight loss in the past year, but some recent weight gain with the swelling. The patient also reported worsening fatigue over the same period of time. He usually awoke fairly rested in the morning but became exhausted during the day with even minimal exertion. He denied any fevers, chills, or night sweats. There was no history of foreign travel, positive PPD, immune suppression, or high risk behavior. Review of systems was positive for 1-3 months of declining urine output, constipation, difficulty chewing, and skin bruising with minimal trauma. He quit smoking cigarettes over 20 years ago. There was no history of MI, CVA, diabetes, or COPD.

He was admitted to an outside hospital 3 days prior to transfer where a pleural effusion was found. The fluid grew methicillin-resistant staphylococcus aureus (MRSA). A chest tube was placed and he was treated with Vancomycin.

Hypertension
Hyperlipidemia
Abdominal Aortic Aneurysm
Right bundle branch block
Benign prostatic hypertrophy
Gastroesophageal reflux disease
Barrett's esophagus

Appendectomy, Cholecystectomy

(at home prior to admission to JHH)
Metoprolol, Simvistatin, Omprazole

Lives with his wife. Retired construction foreman. Social alcohol, history of cigarettes, no illicit drugs.

Non-contributory

NKDA

* General: thin, ill appearing man in mild respiratory distress
* Vital Signs: T 37.5 C, BP 90/50, P 110, R 23, O2 saturation- 93% on 2 liters
* HEENT: PERRL, TM normal, no mouth lesions, slightly enlarged tongue
* Neck: supple without adenopathy or thyromegaly
* Cardiac: tachycardia, JVP elevated to mid-neck, PMI diffuse, S4, no murmurs
* Chest: decreased breath sounds on right. No wheezes. Crackles bilaterally to 1/3 up chest.
* Abdomen: soft, not distended, normal sounds, no hepato-splenomegaly, stool heme negative.
* GU: slightly enlarged prostate
* Skin: old bruises on the forearms and ankles. No rashes or petechiae. Moderate pitting edema to the knees
* Neurological: decreased sensation bilaterally below the ankles, normal strength and reflexes.

Na- 125, Cl-97, K-5.7, HCO3-16, BUN-76, Cr-4.3, Glu-82
TP-6.0, Alb-2.1, Bili-0.6, LFTs-nl
Hct- 27%, WBC- 8000, Platelets- 215
Urinanalysis- 2+ protein, numerous red cells, no glucose, ketones, white blood cells.

ejection fraction of 45-50% with concentric left ventricular hypertrophy, mild/moderate pulmonary hypertension, enlarged left atrium and right ventricle, findings consistent with impaired diastolic relaxation of left ventricle

Mildly enlarged heart, right chest tube with minimal residual fluid, pulmonary vascular congestion.

bilateral enlarged kidneys with 5.9 cm hypoechoic mass in the upper pole of the right kidney (Figures 1A-C)

confirms solid right upper pole mass, reveals additional solid mass in mid right kidney (Figure 2A-B)

Following transfer to JHH, the patient was begun on hemodialysis for treatment of acute renal failure. However, he developed persistent hypotension and was switched to continuous venovenous hemodialysis (CVVDH) for the remainder of his admission. In addition, he was continued on antibiotics for treatment of MRSA. The patient remained stable for approximately 1 ½ weeks, but abruptly decompensated, becoming febrile and severely hypotensive, requiring vasopressors. He was started empirically on cefepime, but continued to decompensate, becoming increasingly acidemic. He suffered a cardiac arrest one day following the onset of these symptoms. The patient was successfully resuscitated, but remained acidemic and vasopressor-dependent. A family meeting was held and the decision was made for comfort care measures only. The patient expired the same day. An autopsy was performed.

What is the underlying cause of the patient’s recent symptoms and signs, as well as the renal and cardiac findings?