Abstract 11417: Drug Abuse and Abdominal Pain: A case of Cocaine Induced Renal and Cardiac Infarction

Introduction: A 35 year old man presented with sudden onset left-sided chest pain and left flank pain. He had known non-ischemic cardiomyopathy (EF of 40-45%), non compliant with treatment. He was in severe pain with left costovertebral angle tenderness. Initial investigations showed a WBC count of 12,000, troponin of 3.72 and a urinalysis significant for 2+ proteins but no RBCs. Initial ECG showed <1 mm ST segment elevations with T wave inversions in inferior leads. Cardiac catheterization, did not demonstrate any flow limiting disease. Serial ECGs demonstrated a resolution of the aforementioned changes and his troponins trended down. Further review revealed an extensive history of cocaine use confirmed with a positive urine drug screen. Due to worsening abdominal pain, a CT abdomen with contrast was done which showed an acute segmental infarct on the upper pole of left kidney, but a CT angiogram did not show any evidence of obstructing vascular lesion or dissection. He was discharged on oral oxycodone, diltiazem and lisinopril.The patient returned in one week with exertional chest pain that was relieved with sublingual nitroglycerin. ECG on admission showed diffuse T wave inversions which improved in 6 hours. A repeat urine drug screen was positive for cocaine. Troponins peaked at 5.03. He then complained of persistent right flank pain and a repeat CT angiogram showed a new moderate-sized segmental infarct in the mid-pole of the right kidney. His pain was managed with oxycodone and he was eventually discharged home with isosorbide mononitrate, amlodipine and lisinopril. Conclusions: Renal infarcts may be sometimes missed in the absence of imaging, but must be suspected in drug users with flank pain and inferior EKG changes. In this case, it was hypothesized that renal arterial vasospasm led to the infarct; an extension of the known effect of cocaine on coronary vessels. This case highlights the importance of ruling out renal infarction as a cause for persistent abdominal pain. Identification of the cause of infarction is important, so as not to subject patients to long term anticoagulation. Guidelines for the treatment of drug induced renal infarction are lacking and the approach to such patients, as with all substance abusers, is abstinence.