Chronic Pyelonephritis

Obscure

Step 1: View clinicals

A 48-year-old male refugee from the Middle East complains of slowly worsening fatigue, sluggishness, and a lack of concentration over a period of three to four years. Careful questioning reveals a history of intermittent and vague lower back pain for the same duration, which he attributed to 'aging'. He has also experienced recurrent episodes of urinary frequency and dysuria since childhood. He says that these were 'only treated with pills', and it appears that they were not investigated further, due to his socioeconomic status. He does not drink but has smoked heavily to a total of 10 pack years. A complete blood count is significant for a hemoglobin of 9.6 g/dL, with a subsequent blood film demonstrating normocytic normochromic anemia. A tuberculin skin test is found to be negative.


Step 2: Order all relevant investigations

Ultrasound abdomen

The ultrasound scan reveals a small right kidney, measuring 6x3x2 cm (normal: 11x7x3 cm), with an irregular echotexture, cortical scarring, and an echogenic parenchyma. A staghorn calculus is visualized in the right pelvis, with hydronephrosis. The left kidney appears to be normal. There are no perirenal fluid collections or obvious anatomic abnormalities of the genitourinary system.

Urinalysis + Urine Cultures

RBC: 2-3/hpf (2-3) Pus cells: 50-60/hpf (0-4) WBC casts: present Nitrates: negative Proteins: 1+ Cultures: positive for Proteus spp., sensitive to ampicillin and cephalosporins.

Renal function tests

BUN: 16 mg/dL (7 - 20) Serum creatinine: 1.0 mg/dL (0.6 - 1.2) Estimated GFR: 92 mL/min/1.73 m2 (90 - 120) Na+: 136 mEq/L (135 - 145) K+: 4.5 mEq/L (3.5 - 5.3)

X-Ray KUB

A small right kidney with a unilateral staghorn calculus is visualized. No other abnormalities are seen.


Step 3: Select appropriate management

Nephrectomy
Cephalosporins
Dialysis
Extracorporeal shockwave lithotripsy


Score: ★★☆