PMC3666156_01
Abdominal MR scans. (A) January 2003 axial, fat-suppressed, T1-weighted, contrast-enhanced MR image showing normal, left, native, renal parenchyma (and a small superficial renal cyst) (arrow). (B) July 2004 axial, fat-suppressed, T1-weighted, contrast-enhanced MR image showing scarred left native kidney after embolic infarction (arrow).. Abbreviations: MR, magnetic resonance; CT, computed tomography.
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An abdominal MRI scan revealed several splenic infarcts, and his left native kidney, previously with a normal smooth outline (except for a superficial cyst, part of the VHL constellation of renal changes), now had a scarred and shriveled appearance consistent with multiple infarcts (Figure 1A and B).
2011 maximum intensity projection coronal oblique reformat MDCT angiogram showing embolus lodged at the left CFA bifurcation (arrow).. Abbreviations: MDCT, multidimensional computed tomography; CFA - common femoral artery.
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A computed tomography (CT) angiogram disclosed filling defects in the left distal common, proximal, superficial, and profunda femoral arteries (Figure 2), consistent with emboli or focal thrombus.
2011 axial contrast-enhanced MDCT showing nonenhancing infarcted segment of renal transplant cortex (arrow).. Abbreviation: MDCT, multidimensional computed tomography.
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It also revealed clear-cut infarcts in the parenchyma of the transplant kidney (Figure 3), with filling defects visible in a few distal intrarenal branches of the left renal artery.
CT chest and echocardiogram. (A) October 2010 contrast-enhanced axial oblique multidetector CT image showing thinning and calcification in the wall of the LV aneurysm and mural thrombus (arrow). (B) 2-D echocardiogram showing pedunculated LV mural thrombus in the aneurysmal segment (arrow).. Abbreviations: CT, computed tomography; LV, left ventricle; 2-D, two dimensional.
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A repeat TTE revealed normal left ventricular size, an aneurysmal apex with mildly impaired systolic function, and a large mobile pedunculated thrombus at the left ventricular apex; LV thrombus and the aneurysm were also shown on a CT scan of his chest performed at this time (Figure 4A and B).
Case clinical timeline.. Abbreviations: ASLA, activated seven lupus anticoagulant; DRVVT, dilute Russell's viper venom time; APTT, activated partial thromboplastin time; TTE, transthoracic echocardiogram; TOE, transesophageal echocardiogram; LA, left atrium; LV, left ventricular; EF, ejection fraction; IgG, Immunoglobulin G; IgM, Immunoglobulin M; GPI, glycoprotein 1.
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The case timeline is shown as Figure 5.