Point-of-Care Ultrasound in Diagnosing Emphysematous Pyelonephritis

  • Kun-Yu Lee
    Reprint Address: Kun-Yu Lee, Department of Emergency Medicine, Chung Shan Medical University Hospital, No. 110, Section 1, Chien-Kuo N. Road, Taichung, Taiwan, Republic of China
    Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan

    Department of Emergency Medicine, Chung Shan Medical University, Taichung, Taiwan

    Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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      A 57-year-old woman with no known systemic disease presented to the emergency department with abdominal pain and vomiting for 3 days. She was well-oriented, with a body temperature of 36.5°C, blood pressure of 133/80 mm Hg, and tachycardia of 118 beats/min. On abdominal palpation, she had tenderness, with no signs of peritoneal irritation. Right-sided costovertebral angle tenderness was elicited. Laboratory data revealed neutrophil-predominant leukocytosis (13,140/μL), thrombocytopenia (10,000/μL), and hyperglycemia (460 mg/dL), representing a new diagnosis of diabetes at the emergency department. Besides, laboratory investigations also showed acute renal dysfunction (blood urea nitrogen 38 mg/dL; creatinine 1.69 mg/dL; estimated glomerular filtration rate 33 mL/min/1.73 m2), elevated C-reactive protein level (45.486 mg/dL), and a high procalcitonin level (186.14 ng/mL). Urinalysis revealed pyuria and bacteriuria. Point-of-care ultrasound (POCUS) and plain abdominal x-ray studies were performed (Figs. 1 and 2) and a computed tomography (CT) scan of the abdomen was obtained subsequently (Fig. 3).
      Figure 1
      Figure 1Point-of-care ultrasound image showing loss of corticomedullary differentiation (asterisk) and hyperechoic foci with reverberation artifact (arrows) near the hilum of the right kidney.
      Figures 2
      Figures 2Plain abdomen x-ray study showing gas collection over the medial side of the right kidney (arrow).
      Figures 3
      Figures 3Abdominal computed tomography scan with intravenous contrast (coronal view) showing right acute pyelonephritis (asterisk), hydronephrosis without urolithiasis, and free air near the hilum of the right kidney (arrows).


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