Multiorgan With Renal Infarction Following Treatment of Cerebral Infarction
A 72-year-old male patient visited the emergency department with a sudden weakness of the upper and lower left extremity and dysarthria. The patient had a history of diabetes, congestive heart failure and atrial fibrillation, and was currently taking 5 mg of warfarin, while maintaining an international normalized ratio (INR) of 2.0-2.5. The patient's blood pressure was 140/80 mmHg, heart rate 66 bits/min, respiratory rate 20 breaths/min, and body temperature 36.8℃. His mental state was clear with mild dysarthria by neurological exam. Manual Muscle Test grade (Medical Research Council of Great Britain) of his upper left extremity was 2, and lower left was 1. Patient's sensory examination showed normal findings, bilaterally. Brain magnetic resonance image showed that an acute cerebral infarction was recognized (), and low molecular weight heparin was used for 7 days, followed by oral administration of 3 mg warfarin after the 8th day.\nThirteen days after the occurrence of cerebral infarction, the patient complained of mild abdominal pains, nausea, vomiting and presented with paralytic ileus in a simple abdominal X-ray. For physical examination performed on the 14th day, the patient complained the tenderness of the costovertebral angle which persisted during percussion. The laboratory examination showed increased levels of lactate dehydrogenase (LDH) 549 IU/L (normal range, 100-450 IU/L); white blood cell (WBC) 21.58×103/µL; aspartate aminotransferase/alanine aminotransferase (AST/ALT) 191/133 IU/L; blood urea nitrogen (BUN)/Cr 41.4/1.43 mg/dL; C-reactive protein 65.6 mg/L; and procalcitonin 0.16 ng/mL, with INR 1.59. Urine analysis showed WBC 0-1/high power field (HPF), red blood cell 1-3/HPF and proteinuria. An abdominal computed tomogram (CT) showed a renal infarction with renal artery occlusion, multifocal splenic infarction and ischemic colitis on the rectum and sigmoid colon (). The patient could not be an indication for use of embolectomy and angiography after 24 hours since the abdominal pain and nausea. Low molecular weight heparin was administered intravenously for 10 days and followed by warfarin, maintaining a INR level of 2.0-3.0, with fluids and antibiotics for the accompanied ischemic colitis. A follow-up laboratory examination was performed after 25 days of occurrence, LDH levels normalized to 418, as well as normalization of AST/ALT 21/12 IU/L, BUN/Cr 16.0/1.02 mg/dL. A follow-up abdominal CT was performed after 43 days of occurrence. There was an improvement of the splenic infarction and ischemic colitis. However, signs of left renal infarction and atrophic change were observed (). During the 12-months follow-up after discharge, there was no symptom or sign of renal dysfunction, such as hypertension or renal failure.