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Background
When painless haematuria is associated with a mass in the flank, severe anaemia and significant weight loss, renal cell carcinoma is highly suspected. In our case, this constellation of symptoms was due to both renal cell carcinoma and a parasitic infestation of Dioctophyma renale (D. renale ), known as giant kidney worms. D. renale is the largest nematode that infects fish-eating mammals including mink, dogs, wolves, coyotes and foxes. Mammals are the definitive host as the nematode prefers to complete its life cycle in the mammalian kidney, with a preference for the right kidney. 1 A review of the literature revealed 20 cases of human infestation reported to date. 1 D. renale has been found in subcutaneous nodules, 2 3 the right kidney, 4-6 the left kidney, 7 bilateral kidneys, 1 8 the retroperitoneal space 1 9 and the liver. 10 One case also described an adult man in whom D. renale infection occurred simultaneously with malignant fibrous histiocytoma of the ureter. 11 This case is unique as it is the first reported case of human D. renale infection with associated renal cell carcinoma and the second reported case of D. renale infection of the left kidney alone.
Case presentation
A 71-year-old African American male nurse presented with lightheadedness, a 10-month history of painless haematuria and significant unintentional weight loss. He also reported passing elongated red tissue via his urethra for 3 months. He was treated, at a clinic, for presumed schistosomiasis due to a remote history of baptism in the River Jordan. He noted some improvement after treatment with praziquantel and doxycycline. However, he continued to pass blood and elongated erythematous matter via his urethra. He denied recent fresh water swimming and travelling, but reported weekly ingestion of local fish, caught in a river by his family, which may have been undercooked. There were no ill contacts with similar symptoms, to his knowledge.
Investigations
On physical examination, the patient was pale and cachectic. He was tachycardic with otherwise normal vital signs. Physical examination revealed hepatomegaly, a left sided flank mass and gross haematuria. He was severely anaemic with haemoglobin of 4.7 g/dL. Further laboratory testing revealed low albumin, elevated platelets and haematuria, but otherwise normal renal and liver function. CT with and...