A 41-year-old non-insulin dependent diabetic female with transverse myelitis was referred after a 7-day history of fever, generalized malaise, vomiting, increasing breathlessness and oliguria. She was a type 2 diabetic (onset 14 year before), requiring insulin for glucose control. She had been treated with high dose of steroids for transverse myelitis.
Upon admission, the patient appeared confused and obtunded, was febrile (39.0 C), tachycardic (110 beats/min) and hypotensive (90/60 mm Hg). She was conscious but not completely oriented in time and space. Cardiac and respiratory examinations were unremarkable.
Relevant laboratory data were as follows: glucose 31.5 mmol/L, urea of 89 mmol/L, creatinine of 168 μmol/L, sodium of 133 mmol/L, and potassium of 5.2 mmol/L. Her hemoglobin was 7.7 g/dL, hematocrit 24 %, total peripheral white cell count of 17700 with a shift to the left, and a platelet count of 20 000 (Table ). Arterial blood gases showed high anion gap metabolic acidosis. Initial ultrasound showed bilateral enlarged edematous kidneys. An abdominal computed tomography (CT) scan showed diffusely enlarged kidneys, with perinephric edema, extensive gas in the renal tissues and perinephric areas bilaterally (Figure ). She was treated with intravenous fluids, ceftriaxone and amikacin.
Laboratory Findings. Results of hematologic and blood chemical values.
An abdominal computed tomography scan showed diffusely enlarged kidneys, with perinephric edema, extensive gas in the renal tissues and perinephric areas bilaterally.
Because of persistent high fever, hypotension, an increase in the total peripheral white cell count and worsening renal function (Table ) the patient was transferred to the intensive care unit on day two and was treated with intravenous fluids, a tritrated insulin infusion, ceftriaxone, amikacin and inotropic support with dopamine. On review by the urologists, it was thought that conservative management should be attempted given the absence of obstruction of the urinary tract. Blood and urine cultures grew Escherichia Coli senstive to amikacin and ceftiraxone as well as ciprofloxacin.
The patient' s clinical condition improved remarkably over the fourth day of treatment, thus obviating the need for surgery.
A Follow-up CT scan obtained 7 days after the initial study showed global improvement with marked reduction of the gas within the kidneys and a decrease in perinephric edema.
Two weeks after admission to the hospital, during which time she made a steady clinical recovery, her antibiotic was switched to oral ciprofloxacin and fluconazole and was sent home 15 days after admission with a serum creatinine concentration of 124 μmol/L (Table ). A CT scan on discharge showed complete resolution of the renal emphysema.
Upon further review she is clinically well and free of infection.