A 25 year old asian female came with a chief complaint of fever x 1 week, R. flank pain x 2 days, and dysuria. Patient's PMH includes mental retardation. She was admitted 6/2/14 but we saw her for the first time 6/9/14.
Labs showed neutrophilia (87 cells/ml), hyperglycemia (315 mg/dl), increased creatinine (1.44 mg/dl), pyuria (30-40 WBC/hpf), occult blood +++, proteinuria +, bacteruria ++, lymphocytopenia (5.5 cells/ml), SGPT 75 IU/L, CRP 34.5, HbA1c 6.4%.
Patient's general appearance was MN, MD, and acutely ill-looking. Patient states poor appetite and vomiting.
Panamax was administered for fever and mosapride for GI symptoms. Ceftriaxone was started on 6/4/14 under suspicion of acute pyelonephritis. Culture showed candida albicans and gram positive bacilli. Ceftriaxone was continued despite culture results.
Renal sonography showed L. kidney with hydronephrosis and R. kidney with distorted central sinus with hyperechoic spots.
Uncontrasted CT showed small calcifications, and contrasted CT was consistent with hydronephrosis.
Dr. Chen's diagnosis was chronic pyelonephritis (CPN), and the patient was stabilized with ceftriaxone. She is scheduled to be discharged 6/10/14. Lab findings suggest acute pyelonephritis (APN), especially since patient's mother denies previous history of APN or UTI. Yet CT and renal echo provide evidence for a CPN. The unexpected finding of candida albicans on the culture and borderline diabetes mellitus further confound the diagnosis.
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