219 Images in Clinical Medicine www.cmj.ac.kr http://dx.doi.org/10.4068/cmj.2016.52.3.219 Ⓒ Chonnam Medical Journal, 2016 Chonnam Med J 2016;52:219 Corresponding Author: Soo Wan Kim Department of Internal Medicine, Chonnam National University Medical School, 42 Jaebong-ro, Dong-gu, Gwangju 61469, Korea. Tel: +82-62-220-6271, Fax: +82-62-225-8578, E-mail: [email protected] Article History: Received July 9, 2016 Revised July 20, 2016 Accepted July 26, 2016 FIG. 1. An abdominal computed tomography axial image shows wedge-shaped low attenuation lesions in the left kidney at the upper pole, suggesting acute pyelonephritis (A). A three-dimensional computed tomography reconstruction image show anteriorly rotated bilateral kidneys (B). A Case of Acute Pyelonephritis in Bilateral Renal Malrotation Ha Yeon Kim 1 , Seung Jin Lee 2 , Eun Hui Bae 1 , Seong Kwon Ma 1 , and Soo Wan Kim 1, * Departments of 1 Internal Medicine, 2 Radiology, Chonnam National University Medical School, Gwangju, Korea A 71-year-old woman was admitted complaining of left flank pain, and presented with oliguria and hypotension. Pyuria and severe sepsis led to the diagnosis of acute pyelonephritis. An abdominal computed tomography intravenous pyelogram revealed normal-sized kidneys, how- ever, the differentiation between cortex and medulla was poorly determined. The left kidney showed an amorphic, low attenuation lesion that was consistent with acute pyelonephritis (Fig. 1A). Both kidneys were incompletely mal- rotated and anteriorly facing hila were observed. The renal vessels and ureter were located laterally. The right kidney was 5 cm lower than the left kidney, indicating renal ectopia. Mild dilation was found at the proximal ureter of the left kidney. Additionally, a three-dimensional computed tomography reconstruction image showed anteriorly rotated kidneys (Fig. 1B). The patient initially received piperaci- llin-tazobactam empirically, then switched to cefotaxime after detecting an E. coli infection in the bloodstream. Three days later, her hemodynamic state had improved, and she was released from the intensive care unit. Malrotation of the kidney may cause partial obstruction of the ureteropyelic junction, which can cause increased in- cidences of urolithiasis and infection. 1 In our case, the patient had a dilated left ureter (not shown) associated with mild obstruction due to a ureteral deformation and renal malrotation. We assumed that these abnormalities were responsible for her recurrent urinary tract infections as well as the acute pyelonephritis with septic shock. To our knowledge, this is the first case report of a patient diag- nosed with septic shock due to acute pyelonephritis associated with renal malrotation. Furthermore, in patients with recurrent urinary tract infections, thorough image evaluation and assessment of risk factors is important. The abdominal computed tomography intravenous pyelogram is a demonstrably useful diagnostic evaluation tool in patients with renal anomalies. ACKNOWLEDGEMENTS This study was supported by a grant (CRI16013-1) Chonnam National University Hospital Biomedical Res- earch Institute. CONFLICT OF INTEREST STATEMENT None declared. REFERENCE 1. Patil ST, Meshram MM, Kasote AP. Bilateral malrotation and lo- bulation of kidney with altered hilar anatomy: a rare congenital variation. Surg Radiol Anat 2011;33:941-4.

A Case of Acute Pyelonephritis in Bilateral Renal Malrotation

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Page 1: A Case of Acute Pyelonephritis in Bilateral Renal Malrotation

219

Images in Clinical Medicine

www.cmj.ac.kr

http://dx.doi.org/10.4068/cmj.2016.52.3.219Ⓒ Chonnam Medical Journal, 2016 Chonnam Med J 2016;52:219

Corresponding Author:Soo Wan KimDepartment of Internal Medicine, Chonnam National University Medical School, 42 Jaebong-ro, Dong-gu, Gwangju 61469, Korea. Tel: +82-62-220-6271, Fax: +82-62-225-8578, E-mail: [email protected]

Article History:Received July 9, 2016Revised July 20, 2016Accepted July 26, 2016

FIG. 1. An abdominal computed tomog-raphy axial image shows wedge-shaped low attenuation lesions in the left kid-ney at the upper pole, suggesting acutepyelonephritis (A). A three-dimensionalcomputed tomography reconstruction image show anteriorly rotated bilateralkidneys (B).

A Case of Acute Pyelonephritis in Bilateral Renal MalrotationHa Yeon Kim1, Seung Jin Lee2, Eun Hui Bae1, Seong Kwon Ma1, and Soo Wan Kim1,*

Departments of 1Internal Medicine, 2Radiology, Chonnam National University Medical School, Gwangju, Korea

A 71-year-old woman was admitted complaining of left flank pain, and presented with oliguria and hypotension. Pyuria and severe sepsis led to the diagnosis of acute pyelonephritis. An abdominal computed tomography in-travenous pyelogram revealed normal-sized kidneys, how-ever, the differentiation between cortex and medulla was poorly determined. The left kidney showed an amorphic, low attenuation lesion that was consistent with acute pye-lonephritis (Fig. 1A). Both kidneys were incompletely mal-rotated and anteriorly facing hila were observed. The renal vessels and ureter were located laterally. The right kidney was 5 cm lower than the left kidney, indicating renal ectopia. Mild dilation was found at the proximal ureter of the left kidney. Additionally, a three-dimensional computed to-mography reconstruction image showed anteriorly rotated kidneys (Fig. 1B). The patient initially received piperaci-llin-tazobactam empirically, then switched to cefotaxime after detecting an E. coli infection in the bloodstream. Three days later, her hemodynamic state had improved, and she was released from the intensive care unit.

Malrotation of the kidney may cause partial obstruction of the ureteropyelic junction, which can cause increased in-cidences of urolithiasis and infection.1 In our case, the pa-tient had a dilated left ureter (not shown) associated with mild obstruction due to a ureteral deformation and renal malrotation. We assumed that these abnormalities were responsible for her recurrent urinary tract infections as

well as the acute pyelonephritis with septic shock. To our knowledge, this is the first case report of a patient diag-nosed with septic shock due to acute pyelonephritis asso-ciated with renal malrotation. Furthermore, in patients with recurrent urinary tract infections, thorough image evaluation and assessment of risk factors is important. The abdominal computed tomography intravenous pyelogram is a demonstrably useful diagnostic evaluation tool in pa-tients with renal anomalies.

ACKNOWLEDGEMENTS

This study was supported by a grant (CRI16013-1) Chonnam National University Hospital Biomedical Res-earch Institute.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCE

1. Patil ST, Meshram MM, Kasote AP. Bilateral malrotation and lo-bulation of kidney with altered hilar anatomy: a rare congenital variation. Surg Radiol Anat 2011;33:941-4.