Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@medscape.com with the subject line "Case Challenge Suggestion." We look forward to hearing from you.
Background
A 60-year-old man presents to his primary care physician with a 2-week history of gross hematuria. He has had no recent illness or exposure to sick contacts. He reports no fever or chills, shortness of breath, abdominal or flank pain, diarrhea or constipation, nausea or vomiting, fatigue, weight loss, lightheadedness, or weakness. He also denies urinary tract symptoms, including dysuria, frequency, urgency, weak stream, or incomplete emptying.
His medical history is significant for rheumatic fever, mitral valve replacement, and lifelong anticoagulation with warfarin. Otherwise, he states that he is relatively healthy. He missed his most recent appointment with his cardiologist but plans to see him in 2 weeks for follow-up.
The patient is married and works as a postal clerk. He has a 15-pack-year smoking history, although he quit more than 10 years ago. He does not consume alcohol or use illicit drugs. His father received a diagnosis of prostate cancer in his 80s, and his sister recently received a diagnosis of lupus.
Physical Examination and Workup
Upon physical examination, the patient appears well. His temperature is 98.5°F (36.9°C), blood pressure is 134/89 mm Hg, heart rate is 76 beats/min, and respiration rate is 14 breaths/min. Pulse oximetry shows an oxygen saturation of 99% on room air. The lungs are clear to auscultation, and breath sounds are equal. Results of the cardiac examination are unremarkable. No tenderness to palpation of the abdomen or pelvis is noted. Flank tenderness is not appreciated. Capillary refill time is < 2 seconds. Some bruising is observed on the upper extremities, but the rest of the examination reveals no obvious signs of bleeding.
Laboratory studies show the following values:
- WBC count: 9.07 × 109 cells/L (reference range, 4-11 × 109 cells/L)
- Hemoglobin level: 12.0 g/dL (reference range, 13.5-15.5 g/dL)
- Hematocrit: 41.3% (reference range, 45%-52%)
- Platelet count: 304 × 109 cells/L (reference range, 150-400 × 109 cells/L)
- Glucose level: 106 mg/dL (reference range, <160 mg/dL)
- Blood urea nitrogen: 18 mg/dL (reference range, 8-24 mg/dL)
- Creatinine level: 1.04 mg/dL (reference range, 0.9-1.3 mg/dL)
- International normalized ratio (INR): 3.2 (reference range, 2-3)
Urinalysis findings are as follows:
- Grossly bloody urine
- RBC count: > 30 RBCs per high-power field (HPF) (reference range, ≤ 2 RBCs/HPF)
- WBC count: 20-50 WBCs/HPF (reference range, ≤ 2-5 WBCs/HPF)
- Leukocyte esterase and nitrites: Negative
- Few epithelial cells
- No bacteria
The patient's anticoagulation regimen is adjusted, and a subsequent ultrasound does not show any masses, hydronephrosis, or stones.
The patient is referred to a urologist for further evaluation and workup. Two weeks after the initial urology visit, cystoscopy is performed. The findings resemble those shown below in a different patient (Figure 1).
Figure 1.
