RGUII ‐ ID Case:

POPS group

CASE SUMMARY:
A 58 yo female patient, with a history of diabetes, obesity, and UTIs, presented to the ED on
09/30/17 with a chief complaint of worsening RUQ abdominal pain. On 09/20/17 she initially
had acute onset urinary frequency, dysuria, and gross hematuria that was not alleviated by
drinking cranberry juice. She was dxed with cystitis and rxed levofloxacin, which she had taken
for her other UTIs, by her PCP on 09/25/17. However the abx didn’t work and she progressed to
diffuse abd pain that then localized to her RUQ. She had tenderness to palpation in the RUQ,
pyuria, E. coli on blood and urine cx, and was sent for a noncontrast CT of abd/pelvis on
presentation to the ED (9/30/17). She was initially given levofloxacin that was then changed to
ceftriaxone as of 10/2/17. Infectious disease was called in on 10/6/17 for the persisting RUQ
pain, elevated WBC despite abx. She was then sent for another CT scan.
The patient’s PMH includes recurrent UTIs (1-2x/year for the past several years), HTN, DM,
COPD, and depression. She is allergic NKDA. She is a 1PPD smoker and denies any alcohol.
She has no relevant FHx. The patient denies N/V/D, no broken bones or bone pain, no
nephrolithiasis, no pneumaturia, no prior abd/pelvic surgeries, and no prior urologic anatomic
issues.
She is currently taking amlodipine for HTN, insulin for DM, citalopram for depression, nicoderm
patch to stop smoking, and famotidine, in addition to the ceftriaxone she is being given as of
10/6/17.
Upon physical exam she was mildly hypertensive, 138/80, obese, non-agitated, alert and
oriented. She had an O2 sat of 96% on room air. Her lungs are clear to auscultation, she has a
non-distended soft abd with RUQ tenderness with palpation but no rebound tenderness. She
has normally active bowel sounds, and a moderate R CVA tenderness. She has no joint
swelling, no edema, and no rashes.
Her lab work shows continually elevated WBC, with elevated neutrophils throughout her stay
(9/30-10/6). She also had low or no existent lymphocytes. She was hyponatremic when
admitted but now has increased Na to 136 (norm). She has normal K levels. Her Cl and and
CO2 have increased within normal limits from 89-102 (Cl) and 23-17 (CO2). Her BUN has been
consistently elevated from 57 (9/30, 68 (10/1), and 58 (10/6). Her creatinine level has also
fluctuated 3.6 (9/30), 4.32 (10/1), 1.46 (10/6). Her urinalysis shows proteinuria, pyuria, positive
nitrites, and turbid clarity. Both her urinalysis and blood work showed E. Coli >100K colony
forming units. Her CT scan shows an enlarged R kidney, on 9/30 and 10/7, that appeared
hypoperfused with contrast on 10/7/17.

ASSESSMENT (diagnosis & differential):

Demographic considerations in this female diabetic patient increases her risk of recurrent UTI
infections as documented in her history. Chronic cystitis can lead to scarring of the bladder and
impair the normal collapsing function of the intrabladder ureter. This increases the risk for
pyelonephritis due to vesicoureteral reflux. On 9/22 the patient presented with symptoms of
cystitis (dysuria, frequency, gross hematuria) and was prescribed levofloxacin. Subsequently
her symptoms did not improve, indicating either resistance to antibiotics and/or complications of
cystitis. In this case, it is likely that acute cystitis developed into pyelonephritis because of her
risk factors. She also presented with mild CVA tenderness and RUQ pain, which increases the
suspicion for pyelonephritis. On 9/30 the patient presented with labs suggestive of acute renal
impairment (elevated Cr, BUN). Urinalysis corroborated the suspected pyelonephritis from gram
negative causes (proteinuria, pyuria, +nitrites, hematuria). CT shows an enlarged right kidney
with poor visualization of of calyces and renal pelvis and CT+contrast revealed poor perfusion
with hyperintense streaking from papillae to cortex, suggesting an inflammatory process leading
to edema, obstruction of the tubular lumen, and decreased tissue perfusion. Subsequently on
9/30, blood and urine culture both revealed the presence of an E.Coli strain that was resistant to
levofloxacin. On 10/2 the patient was started on ceftriaxone which the E.Coli strain was found to
not be resistant to. Therapy appears efficacious given the improvement in Cr and BUN on 10/6.

While we are most suspicious of pyelonephritis from E.Coli infection, the following remain on the
differential:

Multi-organism infection - always possible but not suggested based on cultures

Abscess formation due to complication of pyelonephritis - potentially a cause of drug resistant
infection; however, it was found that levofloxacin resistance was due to bacterial strain. Further,
CT did not reveal abscess
Acute interstitial nephritis secondary to levofloxacin - could present with azotemia, hematuria,
pyuria, edematous, enlarged parenchyma approximately 1-3 weeks after drug use. However,
other symptoms of rash and fever are not present. Urinalysis and blood panels do not reveal
eosinophilia. Neutrophil predominance favors acute bacterial etiology.
Exacerbation of diabetic nephropathy - possible due to acute bacterial infection leading to
worsening DN. However, we have no evidence of history of DN and this does not account for
CVA tenderness, leukocytosis and other signs of infectious etiology
Neoplasm: always in the differential for older population with gross hematuria; repeat cystitis
can also increase the risk of metaplasia of the bladder and squamous cell carcinoma; however,
not likely given the overt signs of bacterial etiology.
Calculi - not visualized on CT. No previous history. Ignores obvious signs of bacterial etiology.

RECOMMENDATIONS:
Based on this patient’s demographics, labs, urinalysis, CT scan, and urine cultures, we believe
that the patient has acute pyelonephritis due to an ascending E.coli infection. As the cultures
show resistance to levofloxacin and susceptibility to ceftriaxone, we recommend that the patient
continue on a course of ceftriaxone for 5-14 days depending on the clinical response as her
renal function tests appear to be improving on therapy as of 10/6. As this patient has had
recurrent cystitis (1-2 times/year treatment with short course antibiotics), this not only raises the
risk for antibiotic resistance, as is seen in this case, but also can lead to chronic pyelonephritis.
We recommend that this patient take measures to prevent her recurrent cystitis in the future.
These include: ingestion of cranberry products, probiotics, and considering d/cing the
lactobacillus for prophylaxis with trimethoprim-sulfamethoxazole. Finally, it has been seen that
additional risk factors for recurrent cystitis include obesity and diabetes mellitus. Weight loss,
exercise, and glucose control should therefore be discussed with this patient.

REF (if any):

https://www-uptodate-com.elibrary.amc.edu/contents/acute-complicated-urinary-tract-infection-
including-pyelonephritis-in-
adults?search=chronic%20pyelonephritis%20due%20to%20e.coli&source=search_result&selec
tedTitle=1~150&usage_type=default&display_rank=1#H3104360530

https://www-uptodate-com.elibrary.amc.edu/contents/recurrent-urinary-tract-infection-in-
women?search=recurrent%20cystitis&source=search_result&selectedTitle=1~145&usage_type
=default&display_rank=1#H9

https://www-uptodate-com.elibrary.amc.edu/contents/recurrent-urinary-tract-infection-in-
women?search=recurrent%20cystitis&source=search_result&selectedTitle=1~145&usage_type
=default&display_rank=1#H9