A 50-year-old man presented with flu-like symptoms, breathlessness and palpitations. He was in atrial fibrillation on admission and a subsequent transthoracic echocardiogram revealed severe left ventricular impairment. A working diagnosis of viral cardiomyopathy was made and he was commenced on anticoagulation, an angiotensin converting enzyme inhibitor and digoxin.

A week into his admission, he complained of severe right flank pain and developed acute renal failure. Magnetic resonance imaging (MRI) of his abdomen showed evidence of haemorrhagic infarcts in his right kidney and also a splenic infarct suggesting embolic phenomenon (fig 1A,B). His left kidney was noted to be shrunken. A transoesophageal echocardiogram showed left atrial appendage thrombus (fig 1C) which could not be seen on the initial transthoracic study.

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Figure 1 (A and B) Abdominal magnetic resonance images showing evidence of haemorrhagic infarcts in the right kidney and a splenic infarct. (C) Transoesophageal echocardiogram showing left atrial appendage thrombus.

The MRI scan combined with the transoesophageal echocardiogram provided confirmation that the cause for his acute renal failure was secondary to embolic infarct and was not due to renal haemorrhage as initially feared.