Seeing Isn't Always Believing: The Diagnostic Power of Bedside Medicine

Introduction: Compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA), can lead to “Nutcracker syndrome (NCS)”1 This compression can result in higher venous pressures in the renal parenchyma, manifesting as hematuria, flank pain and varicocele. NCS is typically considered a diagnosis of exclusion. We present the case of a 19 year old patient who was referred to vascular surgery for surgical correction of NCS. Case Description: A 19-year-old male with a history of hypertension presented with persistent microscopic hematuria and an episode of gross hematuria, following an upper respiratory tract infection. CT Angiogram suggested LRV compression between the aorta and the SMA, with an 18 degrees aortic-SMA angle. Nephrology review prior to invasive surgery revealed a kidney biopsy with light microscopy findings of glomeruli with minimal mesangial expansion, immunofluorescence revealed diffuse 3+ granular mesangial and segmental capillary loops' reactions for IgA and electron microscopy showed scattered immune complexes in the mesangial areas. Supportive care with renin-angiotensin-aldosterone system blockade was initiated, for the treatment plan for IGA nephropathy (IGAN). Discussion: The “Nutcracker phenomenon” refers to the anatomical compression of the LRV, whereas “Nutcracker syndrome” is used to describe individuals who experience symptoms due to this compression.1 Majority of cases with IGAN have a favourable prognosis.2 In this case, the imaging findings of NCS prompted the consideration of surgical intervention. Given isolated hematuria without typical NCS features, we believe the patient had Nutcracker phenomenon. Hematuria was due to IGAN. It is crucial to weigh the benefits of therapy before proceeding with treatment.