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Answers on p 418.
A 45 year old woman presented to a surgical clinic with an eight month history of intermittent colicky right loin and suprapubic pain associated with nausea, with no exacerbating or relieving factors. She had lost 1 stone (8 kg) in weight over that period. She had no bowel or menstrual disturbance, but did complain of polyuria and nocturia. One year earlier she had been diagnosed as hypothyroid by her general practitioner when she presented with a thyroid swelling and tiredness. Biochemistry at that time confirmed borderline hypothyroidism (free thyroxine 9.8 pmol/l (normal range 10.0–24.0), thyroid stimulating hormone 13.2 mU/l (0.3–4.6), thyroid microsomal antibodies positive, titre 1:1200). She was treated with thyroxine 100 μg daily, with no improvement in her tiredness. She had no other past medical history of note. Cardiorespiratory examination was normal. Examination of the neck showed a stony hard diffusely enlarged thyroid gland, although she was clinically euthyroid. Examination of the abdomen showed tenderness to deep palpation and the suggestion of a mass in the right loin. Biochemical profile showed mild renal impairment with a serum creatinine of 143 μmol/l (50–100), but was otherwise normal. Amylase, thyroid function test, and full blood count were all normal. Erythrocyte sedimentation rate was raised at 72 mm/hour, as was C reactive protein at 28 mg/l (0–10).
A renal ultrasound scan was performed, and then subsequently computed tomography of the abdomen and pelvis (fig 1). The latter showed a markedly hydronephrotic right kidney, and a periaortic soft tissue mass, encasing the aorta, inferior vena cava, and iliac arteries.
- What is the likely diagnosis based on the computed tomogram appearance?
- What is the link with the thyroid abnormality?