• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Acute Pyelonephritis with Perinephric Stranding on CT

Ronald Goubert* and Jonathan Peña, MD*

*University of California, Irvine, Department of Emergency Medicine, Orange, CA

Correspondence should be addressed to Jonathan Peña, MD at jdpena@uci.edu  

DOI: https://doi.org/10.21980/J8BH0VIssue 3:1
Infectious DiseaseRenal/ElectrolytesVisual EM
No ratings yet.

History of present illness:

A 54-year old female presented to the emergency department with complaints of fevers, dysuria, urinary frequency, and diffuse abdominal pain. Her temperature was 103°F, but the remainder of her vital signs were normal. Upon physical examination, the patient had tenderness to palpation in the left upper and left lower abdomen and left costovertebral angle tenderness. Due to the location of pain (diverticulitis is in the differential for left-sided abdominal pain in this age group) and patient’s reported history of nephrolithiasis, a computed tomography (CT) scan of the abdomen and pelvis with intravenous (IV) contrast was ordered because the physician felt this could best work up both of these possible conditions.

Significant findings:

A CT abdomen and pelvis with IV contrast showed neither nephrolithiasis nor diverticulitis, and instead showed heterogeneous enhancement of the left kidney with mild edematous enlargement and striated left nephrogram. Significant perinephric stranding (red arrows) was also noted and was consistent with severe acute pyelonephritis.

Discussion:

Acute pyelonephritis (APN) is a bacterial infection of the renal parenchyma which can present with a spectrum of symptoms including flank pain, high-grade fever, vomiting, and urinary tract symptoms.1,2 The diagnosis of APN can be made based on these clinical features with associated laboratory findings of bacteriuria, pyuria, positive urine cultures, and leukocytosis.1,2,7 Early diagnosis and treatment of APN is essential to prevent complications such as renal abscess or infarct, which could lead to renal failure, sepsis, and shock.3

Computed tomography has a sensitivity and specificity of 86.8% and 87.5%, respectively, for diagnosing APN. Common findings include striated nephrograms or perinephric fat stranding.2 However, imaging is not required for diagnosis and is typically reserved for patients who are immunocompromised, have severe symptoms, or show no clinical improvement 72 hours after initiating antibiotic therapy.2,3,4 The diagnosis acute pyelonephritis is mostly done using clinical judgment. A patient’s history, physical exam, and confirmatory labs including urinalysis is usually sufficient for the diagnosis. Proper diagnosis and treatment of APN has been of increasing concern in community settings due to increasing rates of antimicrobial resistance in uropathogens.5,6,7 Therefore, monitoring of local antibiotic resistance trends through urine cultures is essential for proper management of these patients in the emergency department.7

Topics:

Acute pyelonephritis, perinephric stranding, nephrogram.

References:

  1. Isreal RS, Lowenstein SR, Marx JA, Koziol-McLain J, Svoboda L, Ranniger S. Management of acute pyelonephritis in an emergency department observation unit. Ann Emerg Med. 1991;20(3):253-7.
  2. Stunnell H, Buckley O, Feeney J, Geoghegan T, Browne RF, Torreggiani WC. Imaging of acute pyelonephritis in the adult. EurRadiol. 2007;17(7):1920-1928. doi: 10.1007/s00330-006-0366-3
  3. Chen KC, Hung SW, Seow VK, Chong CF, Wang TL, Li YC, et al. The role of emergency ultrasound for evaluating acute pyelonephritis in the ED. Am J Emerg Med. 2011;29(7):721-724. doi: 10.1016/j.ajem.2010.01.047
  4. Goel RH, Unnikrishnan R, Remer EM. Acute urinary tract disorders.Radiol Clin North Am. 2015;53(6):1273-1292. doi: 10.1016/j.rcl.2015.06.011
  5. Doi Y, Park YS, Rivera JI, Adams-Haduch JM, Hingwe A, Sordillo EM, et al. Community-associated extended-spectrum beta-lactamase–producing Escherichia coli infection in the United States. Clin Infect Dis.2013;56(5):641-648. doi: 10.1093/cid/cis942
  6. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med.2012;366(11):1028-1037. doi: 10.1056/NEJMcp1104429
  7. Park YS, Oh WS, Kim Y, Yeom JS, Choi HK, Kwak YG, et al. Health-care associated acute pyelonephritis is associated with inappropriate empiric antibiotic therapy in the ED. Am J Emerg Med. 2016;34(8):1415-20. doi: 10.1016/j.ajem.2016.04.018
Icon

Pyelonephritis - Case Report

1 file(s) 418 KB
Download
Icon

Pyelonephritis - Images

1 file(s) 107 KB
Download
CTIssue 3:1

Reviews:

No ratings yet.

Please rate this





Empyema

08 Jan, 18

Point-of-care Ultrasound Detection of...

08 Jan, 18
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.