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Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 39-43

Acute pyelonephritis in diabetes mellitus: A series of six cases

1 Department of General Medicine, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Radiodiagnosis, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission15-Jan-2022
Date of Acceptance26-Jan-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Dr. Ravi Kant
Departments of General Medicine, AIIMS, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/upjimi.upjimi_1_22

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Acute pyelonephritis is an inflammation due to infection affecting the kidneys and pelvis. Patients usually present with classical symptoms such as high-grade fever, loin pain, although sometimes present with atypical complaints. Diabetes mellitus is the common cause of pyelonephritis, sometimes increasing the rate of complications in patients with pyelonephritis. The most common organism responsible is Escherichia coli. We are reporting here our experience of six patients with acute pyelonephritis and their outcomes. Early diagnosis and treatment decrease mortality and long-term complications.

Keywords: Acute pyelonephritis, diabetes mellitus, Escherichia coli

How to cite this article:
Ronanki K, Kokila K, Dheeraj, Kumar N, Bairwa M, Kant R. Acute pyelonephritis in diabetes mellitus: A series of six cases. J Intern Med India 2021;15:39-43

How to cite this URL:
Ronanki K, Kokila K, Dheeraj, Kumar N, Bairwa M, Kant R. Acute pyelonephritis in diabetes mellitus: A series of six cases. J Intern Med India [serial online] 2021 [cited 2023 Mar 24];15:39-43. Available from: http://www.upjimi.com/text.asp?2021/15/1/39/343024

  Introduction Top

Acute pyelonephritis is a category of urinary tract infections (UTIs) that can be either complicated or uncomplicated. Acute pyelonephritis has an incidence as high as 250,000 cases per year and requires 100,000 hospitalizations every year in the USA. Women are affected more commonly than men.[1] Pyelonephritis is a bacterial infection of the kidney and renal pelvis and should be usually inferred clinically in patients with flank pain or tenderness with laboratory evidence suggestive of UTI. The typical manifestations of pyelonephritis include fever, chills, and malaise due to systemic inflammation or urgency, urinary frequency, and dysuria. The most common major symptoms are fever and flank pain; however, the clinical presentations and disease severity vary, ranging from low-grade fever mild flank pain to refractory septic shock. Diabetes mellitus (DM) is one of the common causes of acute pyelonephritis. Acute pyelonephritis can precipitate a dysregulated host response[2] that results in fulminant illness which is difficult to treat. Diagnosis is mostly clinical, but computed tomography (CT) or ultrasonography (USG) enhances the precision. The assessment of severity, classifying whether it is complicated or uncomplicated, underlying immunity status, underlying comorbidities, and the isolated pathogen with resistance pattern to antimicrobial agents are critical in decisions regarding the need for hospitalization, management, and the need for vigilant monitoring.

  Case Reports Top

Case 1

A 40-year-old male with a history of hypothyroidism and DM for 10 years on ayurvedic medication presented to the outpatient department with a history of fever persisting for 11 days, right flank pain for 10 days, and burning micturition for 8 days. Fever was not documented, high grade, associated with chills and rigors. Examination revealed right renal angle tenderness and tachypnea with a respiratory rate of twenty-four. The serum creatinine was 1.6 mg/dl and complete blood cell (CBC) revealed mild leukocytosis. Ultrasound of the whole abdomen is normal. Noncontrast computerized tomography was done which was suggestive of bilateral acute pyelonephritis as shown in [Figure 1]. The patient was treated with fluids and intravenous (IV) levofloxacin. The urine culture showed  Escherichia More Details coli sensitive to levofloxacin, and hence the same antibiotic is continued for a total of 14 days. The patient improved clinically with no fever spikes and the serum creatinine was normalized.
Figure 1: Coronal noncontrast computed tomography image showing bilateral bulky kidneys with bilateral perirenal fat stranding

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Case 2

A 62-year-old female with a history of old ischemic cerebrovascular accident for 5 years on antiplatelet therapy and history of DM for the past 2 years with uncontrolled sugars presented with a history of high-grade fever and burning micturition for 10 days and breathlessness for 2 days to the emergency. In an emergency, she was intubated because of respiratory distress with tachypnea. She developed acute kidney injury with deranged serum creatinine and anuria for 10 h not responding to carbapenems. Urine analysis shows plenty of pus cells and Enterococcus species sensitive to linezolid was isolated and antibiotics were changed in accord to it. Ultrasound was s/o gross left hydronephrosis. Noncontrast computed tomography (NCCT) revealed left hydronephrosis without calculi as shown in [Figure 2] and a percutaneous nephrostomy (PCN) drain was inserted by the urology team. The patient clinically improved and got extubated successfully. The patient responded to antibiotics and complete blood count (CBC), kidney function test (KFT) recaptured to normal values.
Figure 2: Axial and coronal noncontrast computed tomography image showing left obstructive ureteric calculus causing upstream gross hydroureteronephrosis with paper thinning of renal parenchyma

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Case 3

A 62-year-old gentleman, who is a known case of DM for the past 8 years was diagnosed with pituitary macroadenoma 3 years ago and was on regular follow-up and planned for surgical excision. He visited with complaints of fever, high grade, and intermittent, documented up to 102 F for the past 15 days. He also gave the history of burning micturition and urgency for the past 5 days, not associated with any abdominal pain. Urine routine microscopy revealed pus cells. Initially, levofloxacin was started and patient symptoms did not improve clinically and piperacillin–tazobactam was added. NCCT kidney, ureter, and bladder were done which revealed bilateral pyelonephritis with calculi in the right upper ureter [Figure 3]. Although urine culture did not add additive benefit by revealing mixed pathogens, the patient responded to antibiotic therapy in 3 days and was completely asymptomatic after 7 days and was discharged.
Figure 3: Axial and coronal noncontrast computed tomography image: hyperdense calculus is seen in the right upper ureter. There is a mild thickening of the upper ureteric wall and right renal pelvis. The right kidney is bulky with perirenal fat stranding and thickening of pararenal fascia. Mild left perirenal fat stranding is also seen

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Case 4

A 55-year-old gentleman, with a history of DM controlled on regular oral hypoglycemic agents, came to the hospital with fever and rigors, vomiting, and headache, persisted for 1 week. There is a history of loin pain without hematuria. On examination, he was conscious, oriented, febrile, and dehydrated with renal angle tenderness. Initial investigations revealed leukocytosis with normal renal functions. Urine microscopy revealed plenty of pus cells, although culture sensitivity did not yield any pathogen. Ultrasound whole abdomen was done which revealed bilateral calculi. NCCT was done which depicted bilateral staghorn calculi with bilateral pyelonephritis [Figure 4]. The patient was started on IV fluids and empirical antibiotics to prevent further enlargement of the stone. The fever subsided and the patient clinically improved. The patient was planned for percutaneous nephrolithotomy by the urology team.
Figure 4: Coronal noncontrast computed tomography image showing bilateral obstructive staghorn calculi with bilateral perirenal fat stranding, bulky right kidney with thickening of the right pararenal fascia

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Case 5

A 42-year-old female, with no prior comorbidities, developed fever for 5 days with chills and rigors, high grade, undocumented, relieved on her own. Fever was associated with abdominal pain of acute onset, periumbilical, nonradiating, a/w decreased urine output for 2 days without frothiness and hematuria. The patient developed altered sensorium for the past 1 day in the form of unresponsiveness and inability to recognize family members. No h/o abnormal body movement or neck stiffness patient presented with the above said complaints to AIIMS and was admitted to the ward. Cerebrospinal fluid was within the normal limit. Tropical fever workup was negative. Urine routine microscopy had 15–20 pus cells; however, urine culture was sterile. USG abdomen was within normal limits. NCCT was suggestive of right pyelonephritis [Figure 5] and was treated with appropriate antibiotics. Baseline investigations revealed increased urea and creatinine and hyperbilirubinemia. The patient received one episode of dialysis for uremic encephalopathy. Hepatitis C serology turned out to be positive. Hepatitis C virus (HCV) RNA polymerase chain reaction has been sent and reports are being awaited. Patient sensorium improved and fever subsided. The patient was discharged with advice to report with HCV viral load report.
Figure 5: Axial noncontrast computed tomography image: bulky right kidney with perinephric fat stranding and thickening of the anterior and posterior pararenal fascia and lateroconal fascia

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Case 6

This 69-year-old female had a history of hypertension and diabetes for the past 18 years on regular medication, diagnosed to have chronic kidney disease stage 4 3 years ago. She developed decreased urine output with pus discharge from urine for 5 days. No history of hematuria, burning micturition, and passage of stones in the urine. His blood picture showed leukocytosis with normal creatinine and blood urea levels. On evaluation was found to have radiological evidence of pyelonephritis on NCCT as shown in [Figure 6]. The patient was started on empirical broad-spectrum antibiotics after sending urine analysis. In-hospital blood sugar control was achieved. E. coli was isolated from urine and was sensitive to piperacillin–tazobactam. Hence, antibiotics were upgraded leading to clinical improvement of the patient.
Figure 6: Axial and coronal noncontrast computed tomography image: showing bilateral perirenal fat stranding. There is thickening of the anterior and posterior pararenal fascia and lateroconal fascia, more on the left side. The small left kidney with thinning of renal parenchyma

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  Discussion Top

The term pyelonephritis denotes inflammation of the renal pelvis and kidney.[3] It occurs usually due to ascending UTI from the urinary bladder to the collecting system. The anatomical localization can be done clinically from the presence of flank pain or renal angle tenderness, but not always. In most uncomplicated UTI patients, the uropathogens present in rectal flora invades the bladder through the urethra. The most common cause of acute pyelonephritis is Gram-negative bacteria E. coli.[4] Other Gram-negative bacteria include Proteus, Klebsiella, and Enterobacter which account for relatively higher proportions of complicated UTIs.

Factors that are modulating risk for acute pyelonephritis include young sexually active women, extreme age groups of patients such as the elderly and due to variability in anatomy and hormonal changes. Pregnant women can also be at risk of developing pyelonephritis, usually in the past two trimesters.[5] Incidence is more in women but has no racial predisposition.[6] Patients with DM are shown to have increased incidence of acute pyelonephritis compared with patients without DM.

The classical presentation includes the triad of flank pain, fever, and nausea or vomiting, but not all symptoms will be present always. Other symptoms include dysuria and hematuria due to concurrent cystitis. The onset of symptoms will be acute usually except in immune-compromised states such as diabetes. A good clinical history and examination is the mainstay of evaluation, but laboratory and imaging studies can be helpful and confirmatory keeping in mind the other differentials of flank pain or tenderness, with or without fever such as acute cholecystitis paraspinous muscle disorders, appendicitis, urolithiasis, and pelvic inflammatory disease.[7] In men, fever plus pyuria, should always raise the suspicion of prostatitis. An infectious cause of pyelonephritis can be evidenced by urine analysis that shows pus cells and urine culture that shows substantial concentrations of a uropathogen, usually Gram-negative bacilli such as E. coli.

Along with urine analysis, including microscopy and cultures,[8] patients with suspected acute pyelonephritis should undergo blood investigations including CBC count to look for leukocytosis, aberrations in serum creatinine, and blood urea to assess kidney function. Further investigations can be prioritized based on the individual patient. A plain abdominal radiography can be done to look for radiopaque calculi specifically of the proximal and distal ureter which can be missed in ultrasound. USG can be used to detect pyelonephritis, but a negative study does not exclude acute pyelonephritis. Ultrasound can detect the size and contour of the kidneys, calculi, mass, abscess, and hydronephrosis if present. However, the imagining study of choice for acute pyelonephritis is abdominal/pelvic CT with better sensitivity, especially in complicated pyelonephritis. However, the imaging study of choice for acute pyelonephritis is abdominal/pelvic CT with better sensitivity, especially in complicated pyelonephritis like emphysematous pyelonephritis. The diagnosis can be made with ultrasound, but CT is typically necessary for emphysematous pyelonephritis and should be aggressively managed. Imaging studies will usually not be required for the diagnosis of acute pyelonephritis but are indicated for patients in septic shock, those patients with poorly controlled diabetes, patients with a renal transplant, complicated UTIs, immunocompromised patients, or with poor clinical response after 72 h.

Acute pyelonephritis can be managed as either outpatient or inpatient. After the assessment of illness severity and associated comorbidities, mildly ill patients who have minimal nausea. Moreover, hemodynamically stable who are young, nonpregnant can be treated as outpatients. Inpatient treatment is usually required for complicated pyelonephritis spectrum, which includes elderly, immunocompromised, those with poorly controlled diabetes, pregnancy, renal transplant patients, patients with structural abnormalities of the urinary tract, with indwelling catheters, or functional abnormalities. The mainstay of treatment of acute pyelonephritis is antibiotics, analgesics, and antipyretics. The initial choice of antibiotics will be empiric and should be based on the local antibiotic resistance. The regimen should be modified when infecting strain is isolated based on the sensitivity. Nitrofurantoin should not be used as it attains concentration only in urine. The Infectious Diseases Society of America recommends empirical therapy with fluoroquinolones if the prevalence of resistance to fluoroquinolones among local uropathogens is <10%.[9],[10] Other choices include oral cephalosporins or TMP-SMX for 14 days. Complicated cases of acute pyelonephritis require IV antibiotic treatment until clinical improvements such as piperacillin–tazobactam, fluoroquinolones, and meropenem for patients with suspicion of methicillin-resistant Staphylococcus aureus and vancomycin can be used. Follow-up urine culture results should be obtained only in patients who had a complicated course and are usually not needed in healthy, nonpregnant women.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician 2005;71:933-42.  Back to cited text no. 1
Talan DA, Takhar SS, Krishnadasan A, Abrahamian FM, Mower WR, Moran GJ, et al. Fluoroquinolone-Resistant and extended-spectrum β-lactamase-producing escherichia coli infections in patients with pyelonephritis, United States(1). Emerg Infect Dis 2016;22:1594-603.  Back to cited text no. 2
Ko YH, Ji YS, Park SY, Kim SJ, Song PH. Procalcitonin determined at emergency department as an early indicator of progression to septic shock in patient with sepsis associated with ureteral calculi. Int Braz J Urol 2016;42:270-6.  Back to cited text no. 3
Scholes D, Hooton TM, Roberts PL, Stapleton AE, Gupta K, Stamm WE. Risk factors for recurrent urinary tract infection in young women. J Infect Dis 2000;182:1177-82.  Back to cited text no. 4
Jolley JA, Wing DA. Pyelonephritis in pregnancy: An update on treatment options for optimal outcomes. Drugs 2010;70:1643-55.  Back to cited text no. 5
Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 2007;45:273-80.  Back to cited text no. 6
Belyayeva M, Jeong JM. Acute Pyelonephritis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Feb 14]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK519537/.  Back to cited text no. 7
Long B, Koyfman A. Best clinical practice: Blood culture utility in the emergency department. J Emerg Med 2016;51:529-39.  Back to cited text no. 8
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the infectious diseases society of America and the European society for microbiology and infectious diseases. Clin Infect Dis 2011;52:e103-20.  Back to cited text no. 9
van Nieuwkoop C, van der Starre WE, Stalenhoef JE, van Aartrijk AM, van der Reijden TJ, Vollaard AM, et al. Treatment duration of febrile urinary tract infection: A pragmatic randomized, double-blind, placebo-controlled non-inferiority trial in men and women. BMC Med 2017;15:70.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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