Unexpected Masses

Case Presentation: A 66 year old African-American woman presented to the ED with 60 lb weight loss over the prior 2 months, increasing confusion, poor oral intake, and foul-smelling urine. She had undergone a left hemicolectomy with colostomy 3 years previously for colon cancer, after which she had refused chemotherapy or other treatment. She had not seen a physician in the intervening 3 years. The family was concerned that she was becoming unable to care for herself. The admitting medical team was highly suspicious for metastatic disease. Vital signs were normal. Examination was significant for mild confusion, cachectic appearance, and no abdominal masses or tenderness. Initial lab work revealed elevated BUN and creatinine, normal hematocrit and a white cell count of 5.1K/mm3. Differential was pending.

Nursing staff attempted to place a foley catheter but were unable to do so due to a "hard, crunchy" obstruction, and she remained incontinent of purulent urine. Imaging studies were limited as the patient refused oral contrast. CT of the head was negative. CT of the chest and abdomen were without masses or evidence of cancer. CT of the pelvis revealed two very large stones in the bladder, one of which had an appendage which was both dilating and obstructing the urethra. There was evidence of bilateral hydronephrosis and hydroureter. Differential from the earlier CBC revealed 95% neutrophils with 36% bands. Antibiotic therapy was initiated. Urologic consultants elected to remove the obstructing stones with suprapubic cystolithotomy. The patient tolerated the procedure well and eventually made a full recovery.

Discussion: Urinary tract infection is a well-documented cause of confusion and failure to thrive in older patients, and should have been higher among the initial differential diagnoses in an older woman with foul-smelling urine and mental status change. Colon cancer has a predilection to metastasize, including to the brain. The presentation of multi-organ system involvement and the concerning history of a cancer that had not been fully treated led us to reach to a conclusion that was not ultimately borne out by the evidence. It is important not to be led astray when hearing the distant hoof-beats of a common problem presenting in an unusual way.

This abstract was submitted as part of an Associate's competition amongst all residents in the state of Massachusetts, and was selected to be presented as a poster at the 2002 Annual Meeting of the ACP-ASIM. The abstract was required to conform to certain size and space restrictions.

Click Here to view the poster that was presented. This file is in PDF format.

Thanks to Stewart Babbott MD, Michael Picchioni MD, and Steven Ryzewicz MD for their assistance in editing this abstract.