Case of the Month 2016-06

Submitted by Peyman Kangavari, MD, and Thomas J. Learch, MD.

A 41-year-old female with past medical history of renal stones and multiple prior urinary tract infections presents to the emergency department complaining of increased urinary frequency, intermittent fever, right flank pain and right upper quadrant abdominal pain. Symptoms have been intermittent for the past two months but has worsened in the past two days. Pain is described as intermittent, severe, "heavy” and “pressure-like” sensation. Pain and fever improve with over the counter NSAIDS. No other alleviating or exacerbating factors. In the past two months, the patient has been treated twice with oral antibiotics for urinary tract infections.

Review of systems was positive for fever, abdominal pain, nausea, polyuria, urinary frequency, and flank pain.

Physical examination in the emergency department was significant for tachycardia, tenderness to palpation in the right upper quadrant.

Initial laboratory findings were significant for severe leukocytosis with left shift, microscopic hematuria, pyuria and elevated urine leukocyte esterase.

Initial imaging work up was performed by Ultrasound of the Abdomen:

For larger images, please click on June 2016 - 1 , June 2016 - 2 , June 2016 - 3 and June 2016 - 4 .

Figures 1-4: Ultrasound images demonstrate markedly enlarged right kidney with loss of the normal renal architecture. There are multiple hypoechoic and anechoic cystic areas in the upper and mid kidney, measuring up to 6 cm at the upper pole, concerning for abscesses or markedly dilated, debris-filled calyces. There are also two large calculi, measuring up to 2.8 cm, in the upper/mid kidney, probably related to the abscesses or dilated calyces described above.

Question 1: What is the differential diagnosis?

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