A 29-year old man was admitted to the emergency department presenting an acute severe bilateral testicular pain radiating to the back. The pain initiated during night, awakening the patient and prompting medical evaluation. He detailed the pain as sharp and continuous, irradiating to his lower back bilaterally and without worsening or alleviating factors. No history of trauma, underlying medical conditions, regular medications or previous surgeries was reported. Abnormal urinary symptoms were also ruled out.
At admission, he was slightly hypotensive (110/60mmHg) with a normal heart rate and normal neurological status. Physical examination was remarkable for a mild dehydration, with pale mucous membranes and cool extremities. Peripheral pulse was symmetric in lower and upper limbs. No heart murmurs, signs of pulmonary congestion or pleural effusion were observed. On abdominal palpation, a lower abdominal mass was noted with mild discomfort. No signs of acute peritonitis were present. Testicular exam was unremarkable.
Anemia (hemoglobin level of 7.6 g/dl and hematocrit of 24%) and acute kidney failure was observed (creatinine 2.8 g/dl, normal blood urea with a estimated Glomerular Filtration Rate of 29 mL/min/1.73 m²). Testicular tumors markers were negative. Abdominal ultrasonography revealed a retroperitoneal mass causing bilateral ureterohydronephrosis. Testes imaging was completely normal.
Contrast-enhanced multiaxial tomography (CT) scan of abdomen and pelvis was deemed necessary, even in the setting of AKI, to establish the definitive diagnosis. It revealed bilateral EIA pseudoaneurysms (Figure 1A) causing moderate bilateral ureterohydronephrosis (Figure 1B) with clear signs of contrast leakage from the right EIA pseudoaneurysm into the retroperitoneum, an evidence of an acute ruptured pseudoaneurysm associated with an ipsilateral retroperitoneal hematoma (Figure 1C). These findings justified acute anemia and renal failure.
The patient was blood-typed and saline expansion was performed. A central left jugular vein catheter was placed in case of acute deterioration and on-call vascular surgery performed a bedside Doppler ultrasonography of the iliac arteries confirming the bilateral enlargement with a turbulent pattern (in comparison to distal or aortic smooth laminar pattern) on the right EIA, thereby confirming the findings of a ruptured right iliac pseudoaneurysm (Figure 2).
Due to the risks of an ongoing bleeding, the patient was submitted to an emergency endovascular repair of the bilateral EIA pseudoaneuryms (Figures 3A, 3B and 3C), ruptured on the right side (as shown in Figure 3D) by the application of bilateral 8 mm (in diameter) x 50 mm (in length) WALLGRAFT® endoprosthesis (Boston Scientific, Marlborough, Massachusetts, United States). After angiographic confirmation of successful treatment with no further bleeding or leakage (Figure 3E and 3F), open inguinotomies were performed for ureterolysis and drainage of retroperitoneal hematoma.
Immediate post-decompression diuresis was observed (with an impressive volume of 12 liters of diuresis on the first 24 hours following the procedure). Creatinine peaked at 3.2 g/dl on the first postoperative day, with the patient reaching a normalized renal function after a week of follow-up. During this period, patient was closely monitored for his hemodynamic condition and renal function recovery, preventing dehydration and electrolyte imbalances.
Hematoma content evacuated from perianeurysmal region as well as conjunctive tissue resected were sent to histopathological analysis and tested for bacteria and fungus. Serologies for acquired infectious disease, inflammatory exams and other specific rheumatological tests (antinuclear factor for lupus and other autoimmune tests) were performed and a multidisciplinary panel of Vascular Surgery, Internal Medicine, Infectious Disease, Rheumatology and Urology fully evaluated the patient. Results were within normal range and cultures were negative. The only identifiable risk factor for cardiovascular disease was cocaine addiction (for the last 2 years).