The Unlikely Duo: Gross Hematuria and Clubbing Revealing Hidden Malignancy

Abstract

A previously healthy 47-year-old Saudi male presented with a two-month history of painless gross hematuria and notable digital clubbing. The hematuria was intermittent, dark red, and unassociated with dysuria, flank pain, or systemic symptoms. Physical examination confirmed clubbing of the fingers, while vital signs and general assessment were unremarkable. Laboratory evaluation revealed mild polycythemia and borderline hypercalcemia, with otherwise normal renal and liver function. Urinalysis excluded infection or glomerular disease, and urinary cytology was negative for urothelial malignancy. Given the combination of persistent hematuria and paraneoplastic signs, imaging studies were prioritized. Renal ultrasonography identified a heterogeneous right upper pole mass, subsequently characterized by contrast-enhanced CT as a 6-cm right renal mass with heterogeneous enhancement and areas of necrosis, consistent with renal cell carcinoma (RCC), without evidence of metastasis. Multidisciplinary discussion favored radical nephrectomy, which was performed successfully with en bloc excision of the kidney, perinephric fat, and regional lymph nodes. Histopathology confirmed clear cell RCC, Fuhrman grade II, with negative margins and no lymphovascular invasion (pT1bN0M0). Postoperatively, hematuria resolved, and early regression of clubbing was observed. This case highlights the diagnostic significance of gross hematuria combined with paraneoplastic manifestations such as clubbing, emphasizing the importance of early imaging and prompt surgical intervention for localized RCC to optimize outcomes.