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Clinical Images

Flank Pain with Oliguria

Joshua Liu, MD and Joel Papak, MD


A 76 year old man with a significant history of coronary artery disease, hypertension and peripheral arterial disease with prior abdominal aortic as well as popliteal aneurysm repairs presented to clinic with subacute oliguria accompanied by bilateral flank pain, fatigue and malaise. He had noticed that his urine production had declined significantly over the past few days. Physical exam was noteworthy for bilateral CVA tenderness. Workup was significant for acute kidney injury with markedly elevated serum creatinine (4.5) from baseline (1). Subsequent CT abdomen and pelvis revealed bilateral common iliac artery aneurysms with inflammatory stranding and calcification resulting in bilateral proximal ureteral obstruction with hydronephrosis (Figure 1). Additional workup was significant for a minimally elevated ESR and CRP, normal urine analysis and normal IgG4 panel.



Which of the following is the most likely cause of the patient's inflammatory common iliac artery aneurysms?

  1. Retroperitoneal fibrosis
  2. Vasculitis
  3. Atherosclerosis-mediated inflammatory disease
  4. IgG4-related disease

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1. Joshua Liu, MD. Resident, Department of Medicine, Oregon Health & Science University, Portland, OR.

2. Joel Papak, MD. Associate Professor of Internal Medicine, Oregon Health & Science University and Portland Veteran Affairs Medical Center, Portland, OR.