Case Study - October 2010

This 32 year old lady presented with left loin pain.

  1. What does the CT scan show (the rest of the CT is unremarkable)?
  2. What is the diagnosis?
  3. What may the other symptoms and signs have been?
  4. What are the most common organisms causing this condition?
  5. What treatment would you recommend?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. The CT scan shows an area of decreased perfusion in the left lower pole anteriorly.
  2. Left pyelonephritis.
  3. Acute pyelonephritis is suggested by flank pain, nausea and vomiting, fever (> 38°C), or costovertebral angle tenderness, and it can occur in the absence of cystitis symptoms (e.g. dysuria, increased frequency).
  4. E Coli, Klebsiella, Proteus, other enterobacteria, staphylococcus.
  5. Hospital admission should be considered if complicating factors cannot be ruled out by available diagnostic procedures and/or the patient has clinical signs and symptoms of sepsis. Supportive and symptomatic treatment such as analgesia, antiemetics and IV fluids should be given as required.
    In mild and moderate cases of acute uncomplicated pyelonephritis oral therapy of 10–14 days is usually sufficient (according to local resistance rates). A fluoroquinolone for 7-10 days can be recommended as first-line therapy if the resistance rate of E.coli is still < 10%.

Patients with severe pyelonephritis who cannot take oral medication because of systemic symptoms such as nausea and vomiting, have to be treated initially with one of the following parenteral antibiotics:

  • a parenteral fluoroquinolone, in communities with E. coli fluoroquinolone-resistance rates < 10%
  • a third-generation cephalosporin, in communities with ESBL-producing E. coli resistance rates 10%
  • an aminopenicillin plus a beta-lactamase-inhibitor in cases of known susceptible Gram-positive pathogens
  • an aminoglycoside or carbapenem in communities with fluoroquinolone and/or ESBL-producing E. coli resistance rates > 10%

After improvement, the patient can be switched to an oral regimen using one of the above-mentioned antibacterials, if active against the infecting organism, to complete the 1–2-week course of therapy

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