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

The cookie setting on this website is set to ‘allow cookies’ to give you the very best experience.

If you continue without changing this setting, you consent to this - but if you want, you can change your setting at any time using the ‘change cookie setting’ link at the bottom of this page.

Cookie Setting

Our Cookies

Cookie NamePurpose
eu_ask This is used to store the cookie setting you set in the form above.
If you choose 'Do Not Allow Cookies' we will need to store this information as a cookie with the value N.
If you choose 'Allow Cookies' or do not make a choice, we will store this information as a cookie with the value Y.

The value is kept for one year.

3rd Party Cookies

Cookie NamePurpose
Google Analytics This website uses Google Analytics, a web analytics service provided by Google, Inc.
Google Analytics sets a cookie in order to evaluate your use of the website and compile reports for us on activity on the website.
Google stores the information collected by the cookie on servers in the United States.
Google may also transfer this information to third parties where required to do so by law,
or where such third parties process the information on Google's behalf.
Google will not associate your IP address with any other data held by Google
By using this website, you consent to the processing of data about you by Google in the manner and for the purposes set out above.

How to reject or delete this cookie