CASE
A 36-year-old white male on active duty with the US Army arrived at our forward surgical hospital in Afghanistan via air evacuation for further evaluation and treatment of diffuse abdominal pain. The patient reported a history of dark, blood-tinged urine approximately 2 weeks earlier. On the day before he presented, he experienced dysuria that he described as “urinating razor blades.” After a restless night, he awoke with stabbing, diffuse pain in the lumbar region and the abdomen. He was evaluated at his local aid station and evacuated to our facility for further treatment.
On arrival, the patient was in moderate distress caused by the continuing abdominal pain that he could not localize. He was otherwise healthy and had no chronic medical problems. The only history worth noting was an uncomplicated appendectomy 2 years previously.
Vital signs were normal, including a temperature of 98.6ºF. Physical examination was remarkable for right costovertebral angle tenderness. The abdomen was nondistended, bowel sounds were absent, and palpation demonstrated guarding throughout the abdomen. A WBC count was unremarkable at 10.1 × 103/µL, and a chemistry profile, which included an amylase determination, was normal except for a minimally elevated creatinine of 1.5 mg/dL. The urine was positive for trace ketones and blood. A Foley catheter was inserted, and the patient was started on IV fluids.
Results of an acute abdominal series of radiographs were unremarkable. CT scans of the abdomen, both with and without contrast, showed a 2-mm stone at the ureterovesical junction with hydronephrosis and hydroureter. Also visualized was a horseshoe kidney, with rupture of the right calyx and extravasation of urine into the peritoneal cavity. IV antibiotics, which had been started previously, then stopped with the finding of a normal WBC count, were added to the patient's IV fluids. The patient was kept NPO and rapidly evacuated out of the combat theater to Landstuhl Regional Army Medical Center (LRAMC) in Germany for further treatment.
A repeat CT evaluation at LRAMC showed no signs of obstruction and no extravasation of urine or fluid in the abdomen. However, a 1.6-cm calcification was noted in the lower pole of the left kidney. Because of the high incidence of ureteral obstruction with horseshoe kidney and the previous CT findings indicating passage of an obstructing calculus, the patient underwent ureteroscopy with ureteral stenting. At follow-up 10 days later, he was pain-free and urinalysis results were normal. A repeat CT of the abdomen confirmed the previously noted 1.6-cm calcification in the lower pole of his left kidney but was otherwise unremarkable. The patient was subsequently reevaluated by Urology and cleared for return to full duty with no restrictions on physical activity.