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56 year old male with HIV/AIDS and a large, symptomatic left renal mass
Past Medical HistoryThe patient is a 56-year old man with multiple severe medical problems including HIV/AIDS and end-stage renal disease presenting with a symptomatic enlarging left renal mass.
The patient was diagnosed with a renal mass (6 x 7 cm) in 07/02, and had a delayed workup due to his multiple severe comorbidities. He developed a pulmonary lesion in 12/03 that was concerning for metastasis. He had undergone several bronchoscopies and been treated empirically for pneumonia. The lesion had in fact decreased in size since getting antibiotics and had since been stable. His bronchoscopies and mediastinoscopy were all negative for AFB, bacteria, fungus and malignancy.
Since 2002, serial imaging studies of his renal mass including multiple CT scans revealed interval increase in size. A renal biopsy was performed in 12/04, which revealed degenerating red cells and proteinaceous material with a fragment of fibrous tissue, no evidence of malignancy. However, his renal mass continued to grow from 7 to 11 cm by the end of 2005, and had caused several episodes of partial small bowel obstruction and chronic abdominal pain. Concurrent chest imaging showed no new lesions nor progression of old lesions.
Despite his extreme surgical risk, the patient felt that he could no longer tolerate his local symptoms and was willing to take all risks necessary in order to attempt surgical removal. Consequently, he was admitted for left radical nephrectomy on 02/10/2006. Over the two months prior to admission, his abdominal pain had gradually worsened and he had an episode of diarrhea in January that required a brief hospital admission. No microbiologic etiology was found for the diarrhea which cleared after rehydration.
The patient was diagnosed with HIV/AIDS in 1997. He had been treated with antiretroviral medications until he stopped these medicines on his own in January 2001. His CD4 count nadir was 14 with a viral load of up to 408,000. In October 2005, anti-retrovirals were restarted; however, his compliance with taking the medications was intermittent. In late November 2005, he had a blood culture positive for mycobacterium avium intracellulare (MAC) and he was started on azithromycin and ethambutol. In December 2005 his absolute CD4 count was 30/mm3.
Past Surgical HistoryExploratory laparotomy for gunshot wound
HIV/AIDS
Chronic active hepatitis B
Hepatitis C
End-stage renal disease, on hemodialysis
Asthma
Hypertension
Coronary artery disease, status post non-ST-elevation myocardial infarction with
percutaneous transluminal coronary angioplasty.
Father died in 40s of "heart disease" and "with alcoholism". Mother is in 70s, alive with hypertension.
Social HistoryHe was single, living with his mother and brother. He was on disability. He has a remote history of injection drug use with cocaine and heroin. He smoked approximately 2 packs per week times 40 years. No alcohol use since 1996.
MedicationsBactrim, Zidovudine, lamivudine, kaletra, tenofovir, azithromycin, ethambutol, metoprolol, nebulizers and aspirin.
AllergiesNo known drug allergies.
Review of Systemsas above.
Physical Exam on Admission
- Blood pressure 142/82, heart rate 100, respiration rate 26, oxygen saturation 100% on 5 liters, temperature 98 degrees. In general, somnolent but arousable to voice, difficult to direct.
- HEENT: Oropharynx free of lesions. Neck: No lymphadenopathy. Supple.
- Chest: Coarse inspiratory rhonchi and rales bilaterally especially at bases. No wheezing.
- Heart: Regular in rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.
- Abdomen: Soft, diffusely tender without rebound, no masses palpated.
- Extremities: +1 lower extremity edema bilateral to knees.
- Rectal: Loose green stool, heme-negative.
- Neurologic: Mental status, somnolent but arousable and oriented x 3, moving all 4 extremities, noncooperative with the remainder of the exam.
- White count 8800; hematocrit 39.6 (baseline = 30)
- Na 145, K 4.3, Cl 101, CO2 27, BUN 24, Cr 5.1, Glu 56,
- Alb 2.9, TP 7.2
- ABG pH= 7.31, PCO2= 31, PO2 72 on room air,
Serial CT Scans of Abdomen and pelvis: (Figures 1-5)
- Figure 1 (February 2004): Avascular, partially calcified, rounded soft tissue mass involving the ventral inferior portion of the kidney
- Figure 2 (February 2004): Coronal and sagittal reconstructions of the left renal mass
- Figure 3 (December 2005): Coronal reconstructions of the left renal mass
- Figure 4 (December 2005): Sagittal reconstructions of expanding left renal mass
- Figure 5 (December 2005): Unenhanced CT scan. Size of the lesion 7.9 to 10.5cm. Extrarenal extension of lesion into upper portion of left psoas muscle.
What is the differential diagnosis for the renal mass in this patient?
Images Click on an image below to enlarge.
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