0:00

So here we have a 58 year old female with a

0:03

history of chronic kidney disease and primary hyperparathyroidism. Whose

0:06

status post parathyroidectomy. Now,

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I'm presenting to the emergency room with left lower

0:12

quadrant pain in urinary urgency.

0:16

the patient reports colicky

0:18

crumpy pain and is unable to sit still.

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So vital signs are within the limits of normal calcium

0:25

is 12.1.

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Now Netflix is suspected and

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a non-con CT is ordered.

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So what do we find in the reading room?

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So what's seen our

0:44

multiple non-obstructing renal calculi measuring up

0:47

to about 4 millimeters bilaterally?

0:50

But there's this well circumscribed 3.9%

0:54

medial to the right power renal space

0:57

which is circles right here.

1:01

So what are our next steps?

1:03

Well, the patients referred for CT guided

1:06

biopsy of this Racha peritoneal power renal

1:09

mass. And here we see sequential images

1:12

obtained during CT fluoroscopy with the

1:15

IR provider advancing their

1:18

needle through a paraspinal approach into the

1:21

mask in question.

1:23

The procedure is actually performed without complication

1:26

and several cores are sent for

1:29

the pathology analysis appropriately informally.

1:33

So what is the path report reveal? Well pathology report

1:36

actually comes seven days later. And in

1:39

this particular case, the final result is granulominous inflammation

1:42

with

1:44

the setting of focal Neurosis. There's

1:47

no evidence of malignancy the acid

1:50

fast microbacterial stain.

1:53

The PSD for Whipple and methanamine Silverstein

1:56

from fungal are also all

1:59

negative.

2:01

So the question for you is approximately what percentage of

2:04

necrotizing granuloma is actually remain unexplained after

2:07

pathological analysis.

2:10

Is it less than 1%

2:12

Is it 10 to 20 percent? Is it

2:15

20 to 30 percent or is it greater than

2:18

35%

2:20

If you said greater than 35 percent you would have been

2:23

spot on so beyond the presence of granulomas

2:26

these masses often remain unresolved in

2:29

etiology.

2:30

the differential remains wide including infections vasculitis

2:33

and autoimmune disease for example

2:36

sarcoidosis

2:39

so in conclusion

2:42

the patient undergoes further worker for nephrolithiasis and

2:45

hypercalcemia

2:46

Interestingly a note she is fond

2:49

of primary hyperparathyroidism.

2:53

And undergoes a repeat parathyroidectomy.

2:57

suggesting that in this particular setting even

3:00

though she had hyperparathyroidism before

3:03

having had a priority.

3:06

She still had residual hyperparathyroidism.

3:10

So no further intervention is performed for her soft

3:13

tissue mass, and she continues to follow up

3:16

with her regular PCP.