Perinephric Abscess


Step 1: View clinicals

A 48-year-old man presents with fever for one week, which was initially low grade and intermittent, but then became high-grade yesterday. He also complains of a dull ache in the upper left abdomen for the same duration. No other symptoms are present. His medical history is significant for type 2 diabetes mellitus for eight years, with poor control, limited dietary compliance and only occasional follow-up. The presence of diabetic complications is unknown. He also experienced an episode of cystitis around one month ago, for the first time in his life. This resolved with antibiotic therapy. He defaulted on the follow-up and has not been evaluated for abnormalities of the urinary tract. He is currently on Metformin 850 mg OD and Gliclazide 30 mg OD. There are known allergies. He does not smoke, but drinks socially. There is no history of intravenous drug abuse. His basic bloodwork reveals a leukocyte count of 16,500/mm3, with 90% neutrophils, a capillary blood sugar of 225 mg/dL (12.5 mmol/L), and normal blood urea and serum creatinine levels.

Step 2: Order all relevant investigations


The urinalysis is unremarkable.

Urine + blood cultures

Culture reports will be available in 48 to 72 hours.

Ultrasound abdomen + pelvis

A hypoechoic collection is seen surrounding the left kidney, separated from it by a thick wall. The left kidney is normal in size, shape, and echotexture, with a normal corticomedullary demarcation. No calculi are noted. The right kidney and the other solid organs remain normal. No intraperitoneal fluid is noted.

CT abdomen + pelvis

There is a large, thick-walled, unilocular collection surrounding the left kidney. There is no extension into the kidney or the surrounding structures. Gerota's fascia is thickened in the posterior aspect. No calculi are noted. A small left-sided pleural effusion is also noted.

Step 3: Select appropriate management

IV antibiotics
Intercostal tube
Percutaneous drainage
Tight glycemic control

Score: ★★☆