A 78-year-old female was admitted to the cardiac critical care unit with concerns for acute on chronic heart failure exacerbation. She had a history of nonischemic cardiomyopathy that had previously remained stable over a period of 15 years through standard medical management.
Six months prior to admission, she developed dyspnea and lower extremity edema. She was treated with diuretics at an outside hospital and ultimately discharged with apixaban after developing atrial fibrillation. Despite outpatient diuresis she continued to feel poorly and developed additional symptoms of fatigue and anorexia, in addition to a 20-lb weight loss over 2 months. She also developed rectal bleeding, which was attributed to the apixaban.
One week prior to admission, she developed suprapubic tenderness, dysuria, and bubbles in her urine. She was diagnosed with a urinary tract infection by her primary care physician and was prescribed nitrofurantoin, which temporarily improved her symptoms, although her dysuria recurred after the course of antibiotics.
She finally presented to our hospital as a direct admission from the cardiology clinic with concerns for ongoing heart failure exacerbation and weight loss driven by cardiac cachexia; however, right heart catheterization demonstrated normal right- and left-sided filling pressures with preserved cardiac index. Throughout this time, she continued complaining of ongoing dysuria and bubbly urine. Further investigation revealed an Enterococcus faecium urinary tract infection and new-onset 7-g proteinuria.
In light of these new clinical data, a reevaluation of the underlying process driving her illness was initiated. Given the history of fatigue, weight loss, edema, and nephrotic-range proteinuria in a nondiabetic elderly patient, there were concerns for nephrotic syndrome secondary to an undiagnosed malignancy. Her recurrent urinary tract infections suggested that an occult malignancy may have produced a colovesical fistula resulting in pneumaturia.
A computed tomography scan of the pelvis showed a large, heterogeneous mass involving the uterus, sigmoid colon, and bladder consistent with sarcoma or carcinoma (Figure). Upon disclosure of these findings, the patient elected for a discharge home under hospice care. She later presented to an outside hospital where biopsy of the mass was consistent with malignancy of colonic origin.
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-Weijia Li, Barton Sanders, MD, Ashita Tolwani, MD
This article originally appeared in the October issue of The American Journal of Medicine.
