Internal Medicine Board Review Course – 2019

A 16-year-old young woman is admitted to the hospital for treatment of acute pyelonephritis. Symptoms and signs that trigger the admission included high fever, chills, nausea and vomiting, pain and tenderness in the left flank, leukocytosis, and numerous white cells and bacteria on microscopic examination of the urine.

She is treated, initially, with ceftriaxone. Subsequently, urine and blood cultures grow E. coli that is sensitive to all antibiotics. No significant improvement is noted after 3 days in the hospital with appropriate doses of ceftriaxone. She remains febrile, has occasional rigors and begins to complain of pain shooting down from the left flank to the groin.

In a patient with acute pyelonephritis, which of the following conditions warrants radiological evaluation?

 failure to improve within 24 hours after appropriate antibiotics
 infection with E. coli species
 symptoms of sepsis
 symptoms consistent with renal colic

Correct Answer:

symptoms consistent with renal colic

Educational Objective:

Recognize indications for imaging studies in patients with acute pyelonephritis.

Key Point:

Possible nephrolithiasis, failure to improve within 72 hours on antibiotics, infections with Pseudomonas and other unusual bacteria are indications for imaging studies in patients with acute pyelonephritis.

Explanation:

This patient’s failure to improve after 72 hours of appropriate antibiotic therapy and the onset of pain radiating to the groin suggest partial ureteral obstruction from a stone. This obviously complicates the management of her pyelonephritis. The stone will probably need to be removed to achieve successful treatment of the pyelonephritis.

Failure to improve within 24 hours after appropriate antibiotics, while concerning, is not an indication to undertake radiological studies. If the clinical picture has not improved in 72 hours, imaging studies are appropriate.

Sepsis itself is not an indication for radiological evaluation. Infection with Pseudomonas or other unusual organisms should prompt radiological evaluation.

Reference:

Nicolle LE and Norrby SR. Approach to the Patient with Urinary Tract Infection in Goldman-Cecil Medicine 2016; 284: 1872-1876

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