Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2014  |  Volume : 25  |  Issue : 5  |  Page : 1059--1061

Unusual presentation of aortic dissection: Post-coital acute paraplegia with renal failure


Dinith P Galabada, Abdul L M Nazar 
 Nephrology and Transplant Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka

Correspondence Address:
Dr. Abdul L M Nazar
Nephrology and Transplant Unit, National Hospital of Sri Lanka, Colombo
Sri Lanka

Abstract

We report the case of a 45-year-old chronic smoker who presented with acute paraplegia occurring during coitus and subsequently developed acute renal failure (ARF) requiring dialysis. He had absent peripheral pulses in the lower limbs with evidence of acute ischemia. Doppler study showed dissecting aneurysm of thoracic aorta, thrombotic occlusion of the distal aorta from L1 level up to bifurcation and occlusion of the right renal artery by a thrombus that was confirmed by magnetic resonance imaging of the spine. He was not subjected to any vascular intervention as his lower limbs were not salvageable due to delay in the diagnosis. Post-coital aortic dissection and aortic dissection presenting with acute paraplegia and ARF are very rare. This is probably the first case report with post-coital acute aortic dissection presenting with paraplegia and ARF. This case emphasizes the importance of a careful examination of peripheral pulses in patients presenting with ARF and paraplegia.



How to cite this article:
Galabada DP, Nazar AL. Unusual presentation of aortic dissection: Post-coital acute paraplegia with renal failure.Saudi J Kidney Dis Transpl 2014;25:1059-1061


How to cite this URL:
Galabada DP, Nazar AL. Unusual presentation of aortic dissection: Post-coital acute paraplegia with renal failure. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Jan 19 ];25:1059-1061
Available from: https://www.sjkdt.org/text.asp?2014/25/5/1059/139940


Full Text

 Introduction



Acute dissection is a lethal aortic disease. More than 90% of the patients with acute aortic dissection complain of severe pain when they present in the emergency department. This con­dition is associated with neurologic sequelae in as many as one-third of the patients. The current literature suggests that aortic dissection results in visceral, renal, cerebral, spinal or limb ische­mia in 25-30% of the cases. Peripheral vascular insufficiency increases overall patient morbidity and early mortality. [1] Unusual presentations of aortic dissection had been recognized in the past. It sometimes mimics other events of vas­cular insufficiency, such as acute myocardial infarction, cerebral ischemia and limb ische­mia. Diagnosis has often been delayed with uncommon presentations. We report a patient with post-coital acute aortic dissection with distal aortic thrombosis presenting with para­plegia and acute renal failure. After a thorough literature review, it was revealed that there are very few cases with aortic dissection presenting with paraplegia and acute renal failure (ARF), and this is probably the first case report with post-coital acute aortic dissection presenting with paraplegia and ARF. This case emphasizes the importance of a careful examination of the peripheral pulses in patients presenting with ARF and paraplegia as it gave the clue to the diagnosis.

 Case Report



A 45-year-old man who was otherwise healthy was transferred to our hospital for further inves­tigation of acute paraplegia. After admission, he developed oliguria. As the renal parameters were raised (blood urea = 30 mmol/L, serum creatinine = 509 μmol/L and potassium = 6.1 mEq/L), he was referred to the nephrology unit.

This patient had developed sudden-onset severe backache during coitus followed by weakness and paresthesia of both legs but without pain, two days before admission.

He was a chronic smoker with 20 pack-years, and his past medical history was unremarkable. There was no history of trauma. He was found to have areflexic paraplegia with loss of all the sensory modalities including proprioception and with a sensory level at T10 at the local hos­pital. Computed tomography of the spine did not reveal any compressive myelopathy and he was transferred to our hospital for magnetic resonance imaging (MRI) of the spine and for further management with the clinical diagnosis of transverse myelitis.

On examination, his pulse rate was 92/min and blood pressure was 120/70 mm Hg in both upper limbs. Bilateral lower limb peripheral arterial pulses were absent and lower limbs were cold and bluish.

Doppler scan revealed dissecting aneurysm of the thoracic aorta from the arch up to the celiac trunk, thrombotic occlusions of distal aorta from the L1 level up to bifurcation and occlusion of the right renal artery by a thrombus. Ultrasound scan showed left-sided hypoplastic kidney. His MRI images are shown in [Figure 1]. It showed dissecting aneurysm of the thoracic aorta with thrombosis in the distal aorta. High creatinine phosphokinase (>40,000 U/L) levels confirmed rhabdomyolysis due to ischemic muscle damage.{Figure 1}

The patient underwent emergency hemodia-lysis, but he was not subjected to any vascular intervention as his lower limbs were not salvageable and surgical intervention would cause more harm from reperfusion injury. He was ma­naged conservatively and died two days later.

 Discussion



Acute aortic dissection presenting with lower limb paralysis is well recognized. Combination of paraplegia and ARF due to acute aortic occlusion is very rare. [2] When acute paraplegia is associated with acute renal failure, vascular etiology has to be considered. This can occur due to aortic occlusion caused by dissecting aneurysm or atheroembolism. This patient had both dissection of aorta and thrombotic occlu­sion of distal aorta.

Paraplegia is caused by occlusion of spinal arteries and occlusion of both renal arteries due to dissection or thrombosis can cause ARF. [2] Aortic occlusion can be complicated by rhabdomyolysis, as in this case, contributing to ARF. This patient's left kidney was hypoplastic and probably non-functioning and therefore occlu­sion of the right renal artery resulted in ARF. Abdominal aortic occlusion can present with acute leg ischemia, lower limb paralysis, acute abdomen and ARF. [3] Acute paraplegia with ARF has also been described in pelvic hematoma, rhabdomyolysis and heroin overdose. [4] Sudden onset peri- or post-coital cardiovas­cular disease is well documented in the litera­ture, including myocardial infarction, pulmo­nary embolus and subarachnoid hemorrhage. The occurrence of aortic dissection in this setting has been rare and reported only twice previously. Lovas and Silver reported a patient with acute aortic dissection with rupture of Berry aneurysm during coitus. [5] Gareth Morris-Stiff et al reported the second case who had sudden unilateral leg pain during coitus and, after six weeks, was found to have aortic dis­section as his lower limb pulses were absent. Therefore, it was postulated that dissection had been slowly progressive over six weeks. [6] In contrast, this case had acute dissection, making the limbs unsalvageable within 48 h.

Clinical examination has a major role to play in diagnosing this condition. Apart from the neurological examination, palpation of peri­pheral pulses and blood pressure measurements in all four limbs is of paramount importance. Limbs should be examined for evidence of acute ischemia. The investigations in such a clinical scenario should start with a Doppler study of the abdominal aorta as a non-invasive method to diagnose aortic thrombus, aneurysm or dissection. Further investigations include ga­dolinium-enhanced MRI and magnetic resonance angiography of the aorta.

Diagnosis of this type of aortic occlusion is difficult to make and often delayed or missed. [7] Aortic occlusion carries a high mortality, ranging from 52-62.5% even after prompt inter-vention. [3] This case emphasizes the importance of including acute aortic dissection in the differential diagnosis of acute paraplegia and the importance of careful examination of the peripheral pulses.

References

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