A 31-year-old male patient with a personal history of a packet smoker/day, pulmonary tuberculosis in childhood, IDDM (treatment with NPH 36-0-26 insulin), traffic accident in 95 requiring surgical intervention.
He came to the emergency department and reported that 15 days before he had started a picture of pollakiuria and dysuria that led him to his bedside doctor, diagnosed with urinary infection and prescribed short antibiotic cycle.
7 days after and after the end of treatment, return to your doctor for pain in the left lumbar region of a constant nature and exacerbation with movement, labelling a mechanical process and treated with muscle relaxants.
Four days after starting the new treatment, the patient suffered a progressive worsening in her general condition accompanied by nausea and vomiting of food content, with chills, thiram and dysuria.
Which the patient decides to discontinue insulin therapy.
Finally, due to the poor evolution (increased pain, drowsiness...) the patient comes to the emergency department.
On arrival, significant glycemic control was detected (Bm test: > 500).
Physical examination revealed: Ta: 37oC.
Fc: 100 l.p.m.
T.A.:118/80.
The patient is conscious, sleepy, acceptably collaborative and oriented in the three axes.
From the neurological point of view there is no focality, nor meningeal signs and pupils are isochoric and normoreactive.
Cardiopulmonary auscultation is characterized by the presence of tachypnea (35 breaths/minute) and isolated snoring in both fields.
Sudorous facies, dry tongue, positive skinfold sign were observed at the head and neck level.
In the abdominal region presents a combined laparotomy scar (median and transversal), a blushing and depressible abdomen, no painful, no defense, no peritonitis data, RHAcu + left lumbar puncture is positive.
Analytical data show the following results: CBC: hematocrit 47%, leukocytes 22000/mm3, platelets 183,000.
Coagulation:TP 17.10 sec. Biochemistry: urea 125 mgr/dl, creatinine 3.5 mgr/dl, k+7.6 mEq/l, Na2+ 108 MEq/l, glucose 1430 mgr/dl
The urine shows sediment: 6-8 episodes per field, 20-25 leukocytes per field, some germs.
Na2+ in urine 108 Meq/l and K+ 14 MEq/l.
Glucosuria and ketonuria:+.
The initial focus was on diabetic ketoacidosis with accompanying urinary instability, so it was decided to go to the ICU before completing studies.
Continuous intravenous infusion with insulin, fluid replacement, acidosis and electrolyte disturbances is initiated in the ICU, starting with empirical antibiotic treatment piperacillin-tafamycin correction + tobramycin.
The simple abdominal X-ray showed an air contour delimiting the left renal silhouette.
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Simultaneously an abdominal echography is performed showing important alterations of the left kidney so it is decided to practice T.A.C. imagery compatible with left emphysematous pyelonephritis, kidney parechyma.
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The clinical picture was diagnosed as emphysematous pyeloneoneitis in diabetic patient suffering from constipation and an urgent surgical intervention was decided.
A lumbotomy incision is made to avoid contamination of the peritoneal cavity.
Edematous perirenal fat, irregular cortical necrotic patchy kidney and conserved capsule are observed.
Located as extra block.
After surgery the patient returns to the intensive care unit requiring the initiation of non-invasive mechanical ventilation, in relation to hypoxemia secondary to the radiological appearance of interstitial infiltrate, which is interpreted as derived from his sepsis situation.
Subsequently, it maintains a good evolution with the evolution of hours, recovering its hemodynamic and ventilatory stability.
Drainage production is minimal and serosanguineous.
The result of hemoactive drugs and the sample culture taken during the intervention were received, both in the growth of an E. Colli sensitive to 3rd generation cephalosporins, beta-blockers, beta-glucemic agents and beta blockers.
Given the results and minimum inhibitory concentrations, it was decided to stop empirical antibiotic therapy changing to quinolones (ciprofloxacin).
Progressively, analytical parameters of renal function and electrolyte disturbances are recovering.
She was discharged 11 days after admission after insulin therapy was adjusted.
Histological analysis of the specimen: extensive areas of hemorrhagic infarction; intense acute pyelonephritis with abscesses extending to perirenal fat; fibrin thrombi in vessels.
