An emergency medical crew brings a 61-year-old woman to the hospital after she developed s… — USMLE Step 2 CK

An emergency medical crew brings a 61-year-old woman to the hospital after she developed severe left flank pain, nausea, and acute confusion over the past 48 hours. Her medical history is notable for type 2 diabetes mellitus and recurrent cystitis. Vital signs include a temperature of $39.4^\circ\text{C}$ ( $102.9^\circ\text{F}$ ), blood pressure of $84/52 \text{ mmHg}$ , pulse of $122/\text{min}$ , and respirations of $24/\text{min}$ . Physical examination reveals marked left costovertebral angle tenderness and a lethargic affect. Laboratory testing demonstrates a leukocyte count of $22,000/\text{mm}^3$ . An unenhanced computed tomography (CT) scan of the abdomen and pelvis reveals a $9\text{-mm}$ calculus lodged in the left proximal ureter, accompanied by severe hydroureteronephrosis and perinephric fat stranding. She is immediately given aggressive intravenous fluid resuscitation and broad-spectrum antibiotics (piperacillin-tazobactam). Two hours later, her blood pressure remains $86/54 \text{ mmHg}$ and her urine output is only $10 \text{ mL/hr}$ . Which of the following is the most appropriate next step in management?

A
Escalation of antimicrobial therapy to meropenem and vancomycin
B
Urgent extracorporeal shock wave lithotripsy
Placement of a percutaneous nephrostomy tubeCevap
D
Administration of oral tamsulosin and ketorolac
E
Repeat computed tomography of the abdomen and pelvis with intravenous contrast

Cevap

The most appropriate next step is the immediate placement of a percutaneous nephrostomy tube (or retrograde ureteral stent) to decompress the infected kidney.

This patient has an obstructing ureteral stone complicated by a severe urinary tract infection and septic shock. In the setting of an infected obstructing stone, the kidney essentially becomes a closed-space infection (pus under pressure). Medical management with intravenous fluids and broad-spectrum antibiotics alone is insufficient because antimicrobial agents cannot adequately penetrate the high-pressure, obstructed collecting system. Immediate surgical decompression is required to achieve source control. This can be safely and effectively accomplished with either a percutaneous nephrostomy tube or a retrograde ureteral stent.

Adım Adım Çözüm

Identify the clinical syndrome.

The patient has septic shock (hypotension, tachycardia, fever, confusion, leukocytosis) secondary to a complicated urinary tract infection.

Vital signs and laboratory values demonstrate a severe systemic inflammatory response and end-organ hypoperfusion.

Localize the source of infection based on imaging.

Initial CT imaging confirms an obstructing 9-mm calculus in the left proximal ureter causing hydronephrosis.

The combination of a severe urinary tract infection and urinary tract obstruction creates a surgical emergency known as an infected obstructed kidney (pyonephrosis).

Determine the appropriate management for the identified emergency.

Immediate surgical decompression via percutaneous nephrostomy or ureteral stent.

Source control is the definitive treatment for sepsis caused by an obstructed, infected organ system. Medical therapy alone is inadequate because antibiotics cannot penetrate the high-pressure, obstructed renal pelvis.

Anahtar Kavram

An infected obstructing ureteral stone is a urologic emergency that requires immediate decompression of the urinary tract (via percutaneous nephrostomy or ureteral stenting) in addition to broad-spectrum antibiotics and hemodynamic resuscitation.

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