Case presentation
A 49-year-old male presented to the hospital emergency department with
left flank pain and hematuria. The patient’s flank pain, which had
started gradually from a week earlier, was intermittent and did not
spread anywhere, but had intensified over the past two days. He also
complained of hematuria along with flank pain occurring once or twice a
day and manifested as voiding of blood clots in his urine. Symptoms of
decreased urinary output, fever, chills, nausea, vomiting, diarrhea, and
dysuria were not mentioned. He had a past history of extensive deep vein
thrombosis (DVT) in the lower right limb about five years earlier. and
as he did not have any provoking factors, thrombophilic tests was
checked and showed negative results (antithrombin III, factor V Leiden ,
lupus anticoagulant, and anti-cardiolipin IgG and IgM). Therefore, he
received 7.5 mg daily warfarin tablets for five years. Six months
earlier, he decided to discontinue treatment and take Aspirin 80 mg
tablet daily without medical consultation. The patient also reported a
history of COVID-19 about three months earlier. He did not report a
history of prolonged travel, surgery, cancer, trauma, or bedridden
state. His sister had a history of DVT and died of pulmonary
thromboembolism due to Lack of cooperation in treatment process. On
examination, the patient was conscious and oriented and his vital signs
were blood pressure 120/80 mmHg, heart rate 126 beats/min, respiratory
rate 19 breaths /min, saturations 96% on room air and body temperature
36.5°C. On physical examination, the heart and lungs were normal and
fatty abdominal distension. No bruit was heard in the renal artery
pathway. Left lower quadrant (LLQ) and costovertebral angle (CVA)
tenderness was detected during abdominal examination. On limb
examination, there was no swelling and both sides had similar sizes and
strong symmetrical pulses. He was referred to the hospital with a color
doppler ultrasound examination of kidneys which showed normal arterial
flow velocity and pattern in intrarenal and main interlobar arteries in
the right kidney. The size and parenchymal thickness of the right kidney
were 129 mm and 16 mm, respectively. No pathological complication was
observed in the right intrarenal and main renal veins. The left kidney
was edematous and swollen leading to the loss of corticomedullary
differentiation. The size and parenchymal thickness of the left kidney
were 168 mm and 25 mm, respectively. A filling defect was evident in the
left renal hilum, suggesting a thrombus measuring 51 × 23 mm in the main
renal vein (Figure 1). Examination of the renal vein at the periphery of
the inferior vena cava (IVC) and its distal portion also showed
extensive thrombosis reaching the site where the vein drains into the
IVC (70 mm in diameter) without evidence of thrombotic spread to the
IVC. IVC had a normal flow. The resistance index of the interlobar
arteries of the left kidney was at the upper normal limit and left renal
arterial flow was normal. Clear recanalization in the left renal vein
was not appraisable.