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A 39 year old woman with a history of ovarian cysts and pyelonephritis presented to our emergency department with the chief complaint of right sided flank pain of 22 hours duration. The pain had been slowly increasing and was severe at presentation. The pain was constant, centered in the right upper quadrant with radiation to the epigastrium, back and lower right quadrant. She had vomited three times prior to presentation. There was no urinary frequency or dysuria and normal bowel movements. No vaginal bleeding or discharge.
The vital signs on presentation were: pulse 88, BP 85/47, RR 12, sat 100 on room air, GCS 15 and T 36.9°C. On examination her skin was cold and clammy and she appeared in some distress. Auscultation of her heart and lungs was normal. She was tender in her upper right quadrant and on percussion over her right kidney without referred or rebound tenderness. While waiting for the results of the blood test the fever increased to 39.2°C and the blood pressure dropped further despite aggressive fluid therapy. Blood cultures were drawn and she received a plasma expander, ceftriaxone 1 g IV and pressors after which she was intubated. A CT was performed that showed inflammation around the right kidney with dilatation of the right urethra and a 6 mm concrement at the vesicourethral junction.
Urinary tract infections range from uncomplicated cystitis to urosepsis and are relatively common presentations at most emergency departments. Urosepsis classically presents with fever, confusion, generalized weakness, tachycardia and dehydration and eventually hypotension and severe sepsis with organ dysfunction. It is most likely to occur in patients with urinary obstruction or indwelling catheters and in immunosuppressed patients, those of advanced age or with serious underlying medical problems. In all patients with suspected urosepsis it is of paramount importance to rule out an obstructive calculus as infection in the presence of high grade obstruction from a stone is a urologic emergency that necessitates not only admission, but also immediate urologic intervention in combination with early antibiotic treatment. Delay in drainage can lead to significant morbidity and death.