Introduction
Non-Hodgkin's lymphoma is a common hematological malignancy and secondary involvement of kidney in non-Hodgkin's lymphoma is well documented.1 However, non-Hodgkin's lymphoma presenting as acute renal failure is rare. Hence, this case has been highlighted.
Case Report
A 62-year-old male presented with oliguria of 15 days duration. There was no history suggestive of hematuria, nephritic illness, nephrotic illness, vasculitic illness, or exposure to nephrotoxins. On examination, the patient had pallor. There was no palpable peripheral lymphadenopathy. A mass was palpable in left para-umbilical region of the abdomen. Left testes was enlarged (8 × 10 cm) and hard to feel. Patient was normotensive. The cardiovascular, respiratory, and central nervous systems were grossly normal.
His hemogram showed hemoglobin of 8.0 g/dL, with normal total and differential leukocyte and platelet count. The peripheral film did not show any abnormal cells. His urine sediment was benign with spot urinary sodium of 90 mEq/L and proteinuria of 1 g/day. His urinary uric acid to urinary creatinine ratio was 0:3. He had elevated blood urea (256 mg/dL), serum creatinine (17.7 mg/dL), serum phosphorus (6.0 mg/dL), and serum uric acid (12.1 mg/dL). His serum calcium (8.2 mg/dL) and serum electrolytes were within normal limits. His bone marrow examination was essentially normal. His HIV, HBsAg, and HCV status was negative. His serum alfafetoproteins and β-HCG levels were normal (5.5 ng/mL and 2.5 mU/mL respectively). His Ultrasound examination showed left testicular mass and left para-aortic lymph node enlargement. Multiple hypo-echoic (cystic) renal space occupying lesions (SOLs) were seen in both kidneys. The CT abdomen also revealed multiple hypo-dense space occupying lesions in both kidneys along with a left para-aortic hypo-dense lymph nodal mass (4.8 × 4.2 cm) (). The FNAC from left testicular lesion and renal SOL confirmed the diagnosis of lymphoma.
Figure 1.
The patient was treated with chemotherapy (vincristine, cyclophosphamide, and steroids) and he recovered completely from lymphoma. He required dialytic support for his acute renal failure that showed complete recovery in two weeks time.
Discussion
Primary lymphoma of the kidney is very rare. Secondary involvement of the kidney occurs commonly from either hematogenous dissemination of lymphoma or by direct extension of retro-peritoneal disease. Various autopsy studies have shown renal involvement ranging from 14 to 62% of the cases.Citation[[1]], Citation[[2]], Citation[[3]] Although approximately 1/3 of the patients showed wide spread involvement of the kidneys in patients with lymphoma on autopsy, this rarely causes clinical symptoms.
Computerized tomography with contrast enhancement is currently considered the investigation of choice for both the evaluation of renal involvement as well as the staging of the disease.Citation[[4]] Renal lymphoma has a broad spectrum of imaging manifestations. Typical patterns of renal lymphoma include multiple or solitary masses, diffuse infiltration or invasion from contiguous retro-peritoneal disease.Citation[[5]]
Helical CT in particular improves detection and characterization of lymphomatous renal involvement by optimizing contrast dynamics and data acquisition and is the current modality of the choice for accurate staging of lymphoma. Atypical CT patterns may be encountered and provide a diagnostic challenge and these include spontaneous hemorrhage, necrosis, heterogenous attenuation, cystic transformation, and calcification.Citation[[6]]
Clinical manifestations of renal involvement of lymphoma are due to various factors i.e., disturbances caused by organ infiltration; disturbances caused due to tumor products; and disturbances due to immunologic disorder. Acute renal failure is an unusual manifestation of lymphomatous infiltration of the kidneysCitation[[7]], Citation[[8]], Citation[[9]], Citation[[10]] this can probably be explained by the pattern of development of renal involvement in this disease. Diffuse bilateral involvement of the kidney that can produce acute renal failure is a late manifestation of the disease.Citation[[11]] In out patient acute renal failure seems to be due to renal infiltration.
The interesting feature in this patient is the clinical presentation with acute renal failure, and the detection of focal cystic lesion in both kidneys on imaging. Both these are rare manifestations of non-Hodgkin's testicular lymphoma.
References
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- Hartman D.S., Davis C.J., Goldman S.M., Friedman A.C., Fritzche P. Renal lymphoma radiologic pathologic correlation of 21 cases. Radiology 1982; 144: 759