Fulminating Uremic Pneumonitis Associated
with Acute Ischemic Nephropathy
(Lower Nephron Nephrosis)*
KENNETH M. HEARD, M.D., E. LEONARD POSEY, JR., M.D. and JOHN W. I,ONG, M.D.
I iu a recent article on the subject of uremic pneumonitis, Hopps and Wissler [I] espe- cially emphasized the frequency of this lesion,
noting it in 62 per cent of 107 autopsy cases of
uremia. They also pointed out its relative fre-
quency in cases of uremia of short duration, the
lesion being present in sixteen (84 per cent) of
nineteen patients who had uremia for less than
one week. The case to be described here appears
to be an especially fulminating one, apparently
developing within two days of the onset of acute
renal shutdown, and resulting in the patients
death approximately three days later.
A seventy-five year old white housewife was ad- mitted to the Mississippi Baptist Hospital on the evening of September 16: 1956, complaining of epi- gastric cramping pain. The distress, which had been present since it awakened her from sleep on the night of September 13, was described as constant, moderate and occasionally acute, radiating into the left anterior chest as well as to the left subscapular region. There were no associated gastrointestinal complaints, the patient having continued to eat heartily, although feeling rather full postprandially. There had been no chills, fever or jaundice. The symptoms becoming progressively more intense, the patient sought medical aid after three days.
Previous similar attacks were denied. This admis- sion was the first hospitalization in her life. She had been told by a physician in another state that she had a diseased heart (no cardiorespiratory symptoms could be elicited by our questioning) and an acid stomach because of occasional heartburn, which she relieved symptomatically with baking soda. The only other finding of note in the systemic review was that for fifty-five years an indefinite mass had been present about the umbilicus which occasionally stuck out like an egg. The past history and family history were non-contributory.
Examination revealed the patient to be an alert, cheerful, cooperative elderly woman, well-developed and well-nourished, who did not appear to be acutely ill. Her blood pressure was recorded as 14Oj80 mm. Hg. The respiratory rate was 20 per minute; the pulse rate, 76 per minute; and the temperature, 98.6~. No abnormalities were found on examination of the head, fundi, neck, heart, lungs and breasts. The abdomen was tender to palpation in the epigastrium, right upper quadrant and periumbilical region. Marked percussion tenderness was noted in the right upper quadrant. No rebound phenomenon was elicited. The liver, kidneys and spleen could not be palpated, nor were any masses evident. Peristalsis was moderately hyperactive. An umbilical hernia? egg-sized, was present. No costovertebral angle tenderness was found. Examination of the rectum, pelvis and extremities re- vealed no abnormalities.
On admission the hemoglobin was 13.3 gm. per cent and the hematocrit, 42 volumes per cent. The white blood cells numbered 9,100 per cu. mm. with 70 per cent segmented neutrophils, 23 per cent lymphocytes and 5 per cent monocytes. i\ urine specimen obtained by catheterization had a specific gravity of 1.016, a trace of albumin, no reducing substance and 2 to 6 red blood cells per high power field.
The admission diagnosis was cholelit hiasis with cholecystitis.
On September 17, blood chemistry studies found the serum amylase to be 48 units; the total bilirubin, 1.1 mg. per cent; blood glucose, 106 mg. per cent; alkaline phosphatase, 2.5 Bodansky units; thymol turbidity, 0.7 units; and blood urea nitrogen, 12.8 mg. per cent. Roentgen studies the same day failed to visualize the gallbladder twelve hours following tele- [email protected] administration. Films of the upper gastroin-
testinal tract revealed a small hiatus hernia, but were
otherwise normal. An x-ray of the chest showed the aorta to be tortuous, the cardiac size and contour to be normal, and the lungs free of evidence of disease. The patient was advised to have her gallbladder re-
* From the Departments of Pathology, Medicine and Surgery, Mississippi Baptist Hospital, Jackson, Mississippi.
JANUARY, 1958 157
158 Fulminating Uremic Pneumonitis-Heard et al.
moved at once. She refused surgery because of her husbands absence on business.
By the morning of September 18 there was tempera- ture of ~OOF., distention, nausea, vomiting and marked tenderness in the right upper quadrant of the abdomen with rebound phenomenon. The total white cell count at this time was 20,500 per cu. mm. with 84 per cent segmented neutrophils, 3 per cent neutro- philic bands, 5 per cent lymphocytes and 8 per cent monocytes. It was felt that surgery could not await the husbands return. On consultation, the surgeon agreed that immediate intervention was mandatory.
Surgery was undertaken at 1O:OO A.M. on September 18. The gallbladder was removed with relative ease; the pathologist reported diagnoses of acute chole- cystitis and cholecystolithiasis. Anesthesia was com- pletely uneventful. The patients blood pressure was 120/70 mm. Hg on leaving the operating room. No blood was given during surgery. In the recovery room the blood pressure dropped to 80/O mm. Hg and the patient became slightly cyanotic. Her pulse rate did not exceed 100 beats per minute; it was stated that the pulse always felt much stronger,than the blood pres- sure might indicate. Supportive measures included 500 cc. of whole blood and 50 cc. of a solution of hydrocortisone administered intravenously, oxygen and vasopressors. The response was slow; the patient was not returned to her room for five hours.
By the morning of September 19 she appeared much better clinically. The blood pressure was 94/60 mm. Hg, and the pulse rate was 90 per minute. The lungs were clear. The patient had become oliguric, how- ever, with a total urinary output of only 255 cc. from 7:00 A.M. September 19 to 7:00 A.M. September 20. The daily urine volumes for the remaining hospital days were 192 cc., 770 cc. and 540 cc. Every effort was made to avoid over-hydration and to keep the electrolytic balance as nearly normal as possible. A blood urea nitrogen was 31.3 mg. per cent. A urine specimen obtained from an indwelling bladder cathe- ter had a specific gravity of 1.017, and showed a trace of albumin. Innumerable red cells per high power field were noted. By the morning of September 20 the carbon dioxide combining power was 45.7 volumes per cent; the chlorides, 469 mg. per cent; the potas- sium, 4.6 mEq./L.; the sodium 122.9, mEq./L.; and the blood urea nitrogen, 45 mg. per cent.
Respiratory difficulty appeared on the afternoon of September 20, with orthopnea, cough of a hacking nature and mild cyanosis, unaffected by the admin- istration of oxygen by nasal catheter at 8 L. per minute. There was no clinical evidence of congestive failure; an electrocardiogram was interpreted as being within normal limits. Nevertheless, the patient was given digitalis, but it did not affect the patients condition.
A portable chest x-ray film on the morning of September 21 showed mottled shadows of increased density in both lung fields, extending out from the
hilar regions. The blood urea nitrogen had risen to 54.5 mg. per cent. The carbon dioxide combining power had declined to 37.2 volumes per cent. The chlorides were 478 mg. per cent, the potassium was 5.3 mEq./L. and the sodium was 126.7 mEq./L.
Despite the oliguria, the respiratory difficulty entirely dominated the picture by September 22. Subcrepitant and musical rales were apparent in both lung fields without signs of consolidation. The expira- tory phase was considerably prolonged. Cyanosis was marked. Breathing was of the grunting type. The sensorium became clouded. During the evening small amounts of bloody mucus were obtained on suctioning the trachea. During this entire period the blood pres- sure remained stable around 98/60 mm. Hg, with no cardiac dysfunction becoming apparent.
Breathing was labored in the extreme on the morn- ing of September 23, with much difficulty and effort in expiration. Only a small amount of mucus could be obtained by tracheal aspiration. The patients condition progressively declined as breathing became more impaired. Death occurred at approximately 9:30 A.M.
The chief autopsy findings of interest were in rela- tion to the heart, lungs and kidneys. The left pleural cavity contained approximately 1 L. of straw-colored fluid with some strands of fibrin contained therein. The lungs appeared quite voluminous, filling the pleural cavities. The combined weight of the lungs was 1,300 gm. The lower portion of the trachea, the mainstem bronchi and the segmental bronchi were filled with inspissated, rather firm grayish tan ma- terial. The pleural surfaces, bilaterally, were grayish- blue to pinkish blue but did not appear atelectatic. They varied from subcrepitant to firm on palpation. On transverse section all lobes presented rather uni- form grayish red, moderately firm dry surfaces from which only a moderate amount of foamy fluid could be expressed with rather marked pressure.
Fibrinous pericarditis was present, with a definite membrane of fibrin present over most of the heart. When peeled away this left slightly congested surfaces. The heart weighed 400 gm. There was a moderate degree of calcified atherosclerosis with no significant narrowing of any of the lumens, however, except in the left anterior descending branch. At a point ap- proximately 1.5 cm. from its origin it was narrowed, but not occluded. The endocardium and valves were all essentially neg