A 32-year-old man presents to the emergency department (ED) with the sudden onset of hematemesis. He reports having vomited bright-red blood 3 times during the past 4 hours; the last incident occurred about 1 hour ago. He estimates that he has vomited about a half-cup (approximately 118 mL) of blood each time.
He has been nauseous for several days. He denies having any abdominal pain or any previous episodes of hematemesis; however, he states that he has had black, tarry stools and decreasing urine output for the past several days. He last urinated about 14 hours ago and he currently has no urge to urinate. He denies any significant past medical history. He denies smoking, drinking alcohol, or using illicit drugs. He does not take any medications, including over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), and is not taking herbal supplements. He denies any prior surgeries.
During the past 2 weeks, the patient noticed some swelling in the glands along his neck, but he has no other complaints.
On physical examination, the patient is ill-appearing. His temperature is 98.6°F (37°C). He has a heart rate of 120 bpm, with a regular rhythm, a blood pressure of 100/70 mm Hg, and a respiratory rate of 16 breaths/min. The examination of his head and neck reveals conjunctival pallor. He has enlarged lymph nodes along his bilateral anterior cervical chains. His lungs are clear to auscultation. Auscultation of his heart demonstrates normal sounds. He has a soft, nontender abdomen, without appreciable masses or organomegaly. His rectal examination shows normal tone and black, guaiac-positive stool. The axillary and inguinal lymph nodes are enlarged bilaterally, and he has normal peripheral pulses.
The patient’s laboratory studies show a hemoglobin of 9 g/dL (90 g/L), markedly elevated blood urea nitrogen (BUN) of 180 mg/dL (64.26 mmol/L), serum creatinine of 11.2 mg/dL (990 µmol/L), lactate dehydrogenase (LDH) of 2550 Units/L, uric acid of 41 mg/dL (2438.7 µmol/L), phosphorus of 19.6 mg/dL (6.3 mmol/L), and an erythrocyte sedimentation rate (ESR) of 30 mm/hr. Urine sediment reveals hematuria, leukocyte casts, and many uric acid crystals. The liver function tests and serologic and complement assays are within normal limits.
Based on his clinical appearance and the laboratory analysis, the patient is diagnosed with acute upper gastrointestinal (GI) bleeding and acute renal failure. He undergoes prompt treatment with vigorous intravenous (IV) rehydration, blood transfusion for worsening anemia, and IV ranitidine therapy. The patient is then admitted to the hospital’s intensive care unit (ICU) for further management.
After stabilization, abdominal ultrasonography is performed, which demonstrates enlarged kidneys (right kidney, 12.5 cm, and left kidney, 12.2 cm) without urinary obstruction. His renal parenchyma is hypoechogenic. He then undergoes endoscopy, which demonstrates erosive gastritis. His laboratory values improve with therapy. Multiple biopsies are then taken of his axillary and inguinal lymph nodes, bone marrow, and kidneys. The axillary and inguinal biopsies are reported as histologically reactive. His bone marrow biopsy demonstrates erythroid hyperplasia. A slide from his renal biopsy is shown below
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