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Renal Abscess Kidney Problem

A case of typical renal abscess, Kidney Disease

The patient, female, 68 years old, entered our department on August 13, 2019 due to "recurrent fever for 2 weeks. The patient developed fever, accompanied by chills, chills, transient syncope, no urinary frequency, urinary dysuria, and no cough and sputum symptoms 2 weeks before admission, and went to the local hospital for measurement of body temperature of 40.2 ° C.


Blood test routine for Renal Abscess

WBC 11.7 * 109 / L, N 94.6%, CRP 200.2 mg / L, PCT 91.5 ng / ml, urinary routine:

WBC1 +, head CT: Multiple ischemic infarcts on both sides of the ventricle, center of the semi-oval on both sides, lung CT See obvious abnormalities, abdominal ultrasound: Left renal cyst with calcification of the cyst wall, consider infectious fever.

 

He was given anti-infective therapy with piperacillin and tazobactam. 08-02 blood culture showed ESBL-positive Escherichia coli. Piperacillin and tazobactam were sensitive, but the patient's body temperature did not drop significantly.

08-05 was adjusted to Bia Penan needle is anti-infective, the heat peak is lower than before, and the re-examination of inflammation index is improved.


08-10 Re-examination of blood routine for Renal Problem

WBC 10.5 * 109 / L, N 86.6%, CRP 39.7 mg / L, PCT 1.78 ng / ml, 08-12 Fever again to 39.9 ° C, with chills and chills, recheck blood routine:

WBC 11.1 * 109 / L, N 92.9%, CRP 138.1 mg / L, PCT 0.74 ng / ml, for further diagnosis and treatment of Escherichia coli septicemia. Thus, admitted to hospital.

 

The patient had a history of type 2 diabetes for 1 year, and had taken metformin tablets in the past month. The recent blood glucose control was average.


Heart Brain and Lungs Examination

Clear mind and spirit. There is no difference in heart and lungs. Abdominal flatness, no tenderness, rebound tenderness, liver and spleen below the costal ribs, Murphy's sign (-), no percussion in the liver and both kidneys, mobile dullness (-), no edema in both lower extremities, neurological examination. No obvious abnormalities were seen.

 

Renal Abscess Kidney Problem

The patient had an acute onset, with obvious symptoms of toxic blood, but no obvious localization symptoms. Inflammation indicators increased significantly at the beginning of the onset.

Both sets of 4 bottles of blood culture were ESBL-positive Escherichia coli.

The diagnosis of bloodstream infection was clear and selected according to drug sensitivity.

In the treatment of sensitive antibacterial drugs, the heat peak has decreased and the inflammation index has improved, but the body temperature still fluctuates.

It is necessary to consider the causes of secondary infection, drug-resistant bacterial infection, drug fever, and local lesion formation.

 

After admission, 2 sets of blood were drawn and cultured, and meropenem needle 1 g q8 h was used for anti-infection, considering Escherichia coli septicemia was most likely to invade from the biliary tract, urinary tract, gastrointestinal tract, and respiratory tract. Faint exudation is visible in both lungs.


Full-abdominal CT enhancement

Slightly low-density focus on the left kidney, approximately 23 mm * 21 mm in size, with no enhancement in the middle part after enhancement, moderate enhancement around the periphery, poorly defined borders, kidney abscesses first considered. Tumors to be discharged.

 

08-16 line MR enhancement of the kidney

A type of circular abnormal signal is seen in the left kidney, the size is about 22 * ​​16 mm, a layered signal is seen inside, the upper layer is slightly lower T1 signal T2 slightly higher signal, the lower layer is slightly higher T1 signal T2 slightly High-signal, obvious high-signal in the inner and lower layers of DWI, enhanced ring-shaped enhancement of the scanning capsule wall. No obvious enhancement in the capsule. Consider renal abscess.

 

Patients with enhanced CT and MR both showed renal abscesses, but after admission, high-dose meropenem needle therapy continued to have high fever, the CRP review did not decrease significantly, and the return of blood culture review was negative.

It seems difficult to explain with such a small abscess. Considering that the lung CT of the patient has a dynamic change compared with the external hospital, it cannot be ruled out that the lung lesions are caused.

But re-examination of the lung CT shows that the thin lungs exuded significantly improved.


 

In order to further clarify the diagnosis of renal abscess, at the same time, in order to drain, after excluding contraindications, underwent B-guided renal lesion puncture on 08-19, 5 ml of bloody fluid was drawn out, and the pus was not considered visually. Having fallen into difficulties, it is planned to further improve the inspection.


However, the body temperature of the patient decreased significantly the next day after the puncture. Re-examination of blood routine:

WBC 6.3 * 109 / L, N 69.4%, CRP 61.6 mg / L, PCT 0.23 ng / ml, 08-22 puncture solution bacterial culture returns Escherichia coli ( 2 CFU / sample), the drug sensitivity results were consistent with the blood culture of the external hospital, the patient had a clear diagnosis of renal abscess, and continued the anti-infection treatment with meropenem.


08-26 Re-examination of blood routine:

WBC 5.96 * 109 / L, N 66.1%, CRP 6.8 mg / L, PCT 0.05 ng / ml, re-examination of kidney B ultrasound: cystic mass is visible in the left renal parenchyma, and the cut surface size is about 13 mm * 11 mm, smaller than before.

The patient's body temperature continued to be normal and he was discharged. He was advised to continue the local hospital to consolidate anti-infective treatment for 2 weeks.

 

Urinary tract infections usually caused by Enterobacteriaceae bacteria

Kidney abscesses can be complicated by urinary tract infections (usually caused by Enterobacteriaceae bacteria) or secondary to bloodborne infections (mostly caused by Staphylococcus aureus), the main pathogens are Escherichia coli and Staphylococcus aureus and Klebsiellapneumoniae.

Susceptibility factors for renal abscesses include diabetes, pregnancy, and abnormal anatomy of the urinary tract.

This patient has a diabetic basis and abnormal urinary white blood cells in the outpatient hospital. It is considered that the most likely cause is a urinary infection.

 

There are three main treatment methods for renal abscesses:

Drug treatment, puncture drainage and surgical treatment, of which antibacterial drug treatment is the most basic treatment. The indication for renal abscess drainage depends on the size of the abscess.

The diameter of the abscess is less than 5 cm. Generally, medical antimicrobial treatment is selected.

If the patient still has clinical symptoms and imaging findings after a few days of treatment, percutaneous drainage may be considered.

If the abscess is> 5 cm, percutaneous drainage combined with antimicrobial therapy should be taken.

It is recommended to continue antimicrobial therapy throughout the entire drainage period and after the completion of drainage.

The total duration of treatment is at least 2-3 weeks. If antimicrobial drugs and puncture drainage cannot successfully treat abscesses or anatomical abnormalities in the urinary tract, surgical intervention may be required.

 

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