Right flank pain and fever!!!!!!!!

[unseennude]

The pathology in the radiological images has be shown by arrow heads.



A 56-year-old man with history of hepatitis C and diabetes mellitus presents to the emergency department with right flank pain and subjective fevers of 2-3 days' duration. The patient describes his pain as mild in intensity but constant. It is nonradiating, with a pressure-like quality. The patient takes 20 units of neutral protamine hagedorn (NPH) insulin injected subcutaneously twice daily for his diabetes but states that his self-reported daily blood glucometer readings have been approximately 250-350 mg/dL for the past month.

On physical examination, vital signs are a blood pressure of 100/60 mm Hg, a heart rate of 96 beats per minute, a respiratory rate of 16 breaths per minute, and an oral temperature of 39.0°C. The cardiac and respiratory portions of the examination are unremarkable. The patient is noted to have tenderness in the right costovertebral angle. His abdominal examination is unremarkable for any tenderness to palpation, rebound, or guarding.

Clinically significant laboratory results include a WBC of 24.4 X 109/L, a blood urea nitrogen concentration of 71 mg/dL, a creatinine level of 5.4 mg/dL, and a serum glucose level 629 mg/dL. Urinalysis reveals cloudy urine with copious WBCs, a glucose concentration of 100 mg/dL, a protein concentration of 100 mg/dL, and large leukocyte esterase.

Renal ultrasonography is performed and reveals an abnormality of the right kidney (see Images 1-2). To further illustrate this abnormality, an abdominal CT scan was obtained (see Image 3). What is the diagnosis?
HINT: This condition most commonly occurs in patients with diabetes

[chetnarayan]

can't any xenomed answer this???

[chetnarayan]

1. the patient is febrile >>>>high fever,
2. his leukocyte count is very high
3. he has loin pain >> right flank pain
4. he has uncontrolled diabets

CT scan shows stone in gall bladder and some kind of abnormality in right kidney.His right kidney is not functioning well
diabetes is his uncontrolled problem!


the patient seems to be ::: suffering from uncontrolled diabetes with acute pyelonephritis

may not be i am all correct ..........

will any clinical students help me find the right tract...........????

[unseennude]

Dear Chetnarayan,

Thank you very much for your approach. You are almost all correct. Let me give you some more hints for this radiological image that will help you to diagnose this patient.

Sonograms of the right kidney (see Images 1-2) show several hyperechoic foci (arrows) in the upper pole with dirty acoustic shadowing (arrowheads).These findings are suggestive of gas in the renal parenchyma.

Nonenhanced CT scans (see image 3) confirmed the abnormalities noted on the sonograms by clearly demonstrating air in the renal parenchyma (arrows).

I think this will help you further more. Good luck.

[Psychic]

Diagnosis:ENP(emphysematous pyelonephritis)

EPN is a severe infection of the renal parenchyma, with the accumulation of gas in the tissues. The factors that predispose to EPN in persons with diabetes are thought to be uncontrolled diabetes, high levels of glycosylated hemoglobin or high levels of blood sugar and impaired host immune mechanisms.

Patients typically present with fever (79%), abdominal or flank pain (71%), nausea and vomiting (17%), dyspnea (13%), acute renal impairment (35%), altered sensorium (19%), shock (29%), and thrombocytopenia (46%). Crepitus over the flank area may occur in advanced cases of EPN. Pneumaturia is uncommon unless emphysematous cystitis is present. Bilateral EPN has also been reported. Alcoholism, malnourishment, renal calculi, and diabetic ketoacidosis are coexisting comorbidities.

Laboratory data reveal leukocytosis with a left shift, pyuria, infected urine, thrombocytopenia, an elevated creatinine level, and positive results from blood culture.
Renal ultrasound images often reveal high echogenic areas with dirty shadowing. Hydronephrosis and perinephric fluid may also be seen.CT scan is the definitive test,several patterns have been described, including streaky, streaky and mottled, and streaky and bubbly,gas can be rimlike or crescent-shaped in the perinephric area,gas can also be seen in the renal vein or inferior vena cava.


Medical therapy: Prompt hydration, fluid resuscitation, and treatment with systemic antibiotics are the mainstays of management and control of diabetes should be achieved quickly,percutaneous drainage is usful in EPN.Nephrectomy is the treatment of choice in most patients with EPN.

thankx for ur HINT unseennude..hope this helps

[unseennude]

You are absolutely correct dear Psychic.
That patient was suffering from Emphyematous Pyelonephritis (EPN).


Emphysematous pyelonephritis (EPN): Sonograms of the right kidney (see Images 1-2) show several hyperechoic foci (arrows) in the upper pole with dirty acoustic shadowing (arrowheads). These findings are suggestive of gas in the renal parenchyma. Nonenhanced CT scans confirmed the abnormalities noted on the sonograms by clearly demonstrating air in the renal parenchyma (arrows). These radiographic findings were consistent with a diagnosis of EPN. Several small calculi are also incidentally noted in the gallbladder (arrowheads).

EPN is a rare, life-threatening, necrotizing infection of the renal parenchyma and perirenal tissues caused by pathogenic gas-forming bacteria. The primary organisms identified routinely on urine culture in this condition are Escherichia coli (66 %) and Klebsiella (26%) and Proteus (<10%) species. The vast majority of patients have underlying, poorly controlled diabetes mellitus. Most of the rest have obstructive uropathy, papillary necrosis, or clinically significant functional impairment.

The pathogenesis of EPN is poorly understood. Some suggest that high glucose concentrations allow organisms such as E coli to proliferate and produce carbon dioxide. However, this reasoning does not account for the infrequency of EPN despite the regularity of urinary infections in patients with diabetes. The disease is most likely an advanced form of pyelonephritis rather than a specific and unique clinical entity. Furthermore, the pathogenesis of EPN is likely multifactorial in distinction to an acute kidney infection, which may occur in otherwise healthy patients or in patients with a clearly identifiable risk factor (eg, structural or functional alterations in the urinary tract, underlying immunodeficiency state).

EPN is usually unilateral, with only 5-7% of cases occurring bilaterally. All known cases of EPN have occurred in adults. The clinical presentation resembles that of acute pyelonephritis, with fever, chills, flank pain, nausea, vomiting, and dysuria. Patients may present with sepsis, confusion, lethargy, or coma (in advanced disease). The diagnosis is typically considered only after treatment for suspected pyelonephritis fails, as the lack of distinct clinical manifestations conceals the condition's presence.

Because of the inability to identify EPN on the basis of clinical findings alone, the diagnosis must be verified with radiographic findings. Plain abdominal radiographs may show gas in or around the affected kidney; however, the inability to differentiate renal gas from overlying bowel gas may preclude a definitive interpretation of the results. Ultrasonography characteristically shows distinctly echogenic areas in the renal parenchyma and perinephric tissues, often with low-level dirty acoustic shadowing in the posterior aspects. Because of potentially diffuse shadowing due to gas, the depth of parenchymal involvement may be underestimated, and renal calculi may be obscured. CT is the preferred imaging modality for definitive diagnosis. CT scanning can also define the presence of renal calculi and the extent of infection.

A classification scheme based on CT findings divides EPN into 2 types; the differentiation has prognostic implications. Type I EPN is characterized by parenchymal destruction with streaky or mottled gas collections and absence of fluid collections. Type II EPN is distinguished by bubbly or loculated gas in the parenchyma or collecting system with associated renal or perirenal fluid. These fluid collections are thought to represent a favorable immune response consisting of exudates and inflammatory cells. Type I EPN is associated with a significantly increased mortality rate approaching 70% versus a rate of 18% for type II EPN.

First-line treatment for EPN includes aggressive fluid support, correction of electrolyte and acid-base irregularities, hyperglycemic control, and intravenous administration of broad-spectrum antibiotics. Subsequent therapy is focused on not only relief of any obstruction of the affected kidney to preserve remaining function, but also consideration for percutaneous drainage of any fluid collections in the affected kidney. Despite aggressive therapy, many patients have a fulminant clinical course, unsuccessful drainage, or failed conservative therapy. These patients may require urgent nephrectomy. The patient in this case responded to medical management with intravenous antibiotics and was discharged home after a prolonged hospitalization.

For more information on EPN, see Emphysematous Pyelonephritis (within the Internal Medicine specialty).