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Emphysematous Pyelonephritis

Full of Air

Step 1: View clinicals

A 64 year old lady presents with dysuria, suprapubic pain, and nausea and vomiting for 3 days. She also complains of right flank pain and fever since yesterday. She has been on treatment for diabetes and hypertension for the last 8 years, with poor control, and is currently on insulin, losartan and amlodipine. She had temporarily stopped insulin for the last 3 days, given her reduced food intake. She also underwent extracorporeal shock wave lithotripsy for recurrent renal calculi last year. A complete blood count is significant for a leukocyte count of 12,500/mm3, while a random plasma glucose level is 917 mg/dL.

Step 2: Order all relevant investigations

Metabolic Profile

Na+: 125 mEq/L (135-145) K+: 5.6 mEq/L (3.7-5.2) Cl-: 95 mEq/L (96-106) HCO3-: 24 mEq/L (23-29) Blood Urea Nitrogen: 44 mg/dL (6-20) Serum Creatinine: 1.8 mg/dL (0.5-1.5)

Urinalysis + Urine & Blood Cultures

Urinalysis: Appearance: Turbid WBC: >100/hpf (normal: ≤5) RBC: >100/hpf (normal: ≤3) Bacterial: 4+ Casts: white cell casts present Nitrates: positive Culture reports will be available in 3 days.

Arterial Blood Gases

On Room Air SaO2: 96% (94 - 100) pH: 7.39 (7.38 - 7.42) PaO2: 78 mmHg (75 - 100) PaCO2: 40 mmHg (38 - 42) HCO3: 23 mEq/L (22 - 28)

Noncontrast CT Abdomen + Pelvis

There is marked R/s hydronephrosis, with calculi, perinephric fat stranding, and gas in the renal pelvis and parenchyma. The left kidney appears normal. No other abnormalities are noted.

Step 3: Select appropriate management

IV Antibiotics Stat
IV 0.9% Saline Bolus Stat
Insulin Bolus Stat
Urgent R/s Nephrectomy

Score: ★★☆