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J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13233
EMP213233
Videos in Emergency Medicine
Videos in Emergency Medicine
Urology
A young man with flank pain and dysuria
WILSON et al.
Wilson Matthew S. MD 1
Miles Michael S. MD 2 2
Frisch Jaysun G. DO 1
Mahr Rosalia M. MD 1
Prats Michael I. MD https://orcid.org/0000-0002-1736-7912
1 michael.prats@osumc.edu

1 Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus Ohio USA
2 Present address: Emergency Physicians Integrated Care, LLC Salt Lake City Utah USA
* Correspondence
Michael I. Prats, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
Email: michael.prats@osumc.edu

19 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1323311 6 2024
04 3 2024
17 6 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

point‐of‐care systems
pyelitis
ultrasonography
source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:20.09.2024
Wilson MS , Miles MS , Frisch JG , Mahr RM , Prats MI . A young man with flank pain and dysuria. JACEP Open. 2024;5 :e13233. 10.1002/emp2.13233
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pmcA 22‐year‐old man with past medical history of type 1 diabetes, intravenous polysubstance use, bacterial endocarditis, and frequent urinary tract infections presented to the emergency department with left‐sided flank pain and dysuria. The pain had been worsening over the last 3–4 days and associated with dysuria, foul smelling urine, and urine “clumps.” He was noted to be ill‐appearing with left costovertebral angle tenderness. Vital signs were heart rate of 114 bpm, blood pressure of 122/66, temperature of 37.5°C, respiratory rate of 18 breaths per minute, and pulse oximetry of 97% on room air. Labs were notable for blood glucose 431 mg/dL, beta hydroxybutyrate 2.83 mmol/L, leukocytosis of 13.2 K/µL, creatinine 1.15 mg/dL, and normal lactate. Urinalysis was consistent with infection. Ultrasound showed a hyperechoic area in the renal pelvis with heterogenous appearing posterior acoustic shadowing (Figure 1, Video 1).

FIGURE 1 Ultrasound image of the kidney showing hyperechoic gas within the renal pelvis (arrow), accompanied by heterogenous shadowing (asterisk).

VIDEO 1 Ultrasound image of the kidney showing hyperechoic air within the renal pelvis and calyces with its characteristic heterogenous shadowing.

1 DIAGNOSIS

1.1 Emphysematous pyelitis

Ultrasound images were consistent with gas within the renal pelvis. Computed tomography, urinalysis, and subsequent urine culture supported the diagnosis of emphysematous pyelitis with candida tropicalis as the causative agent. The patient was admitted to the hospital where he was treated with a 3‐week course of caspofungin and placement of a percutaneous nephrostomy tube. His postdischarge course was complicated by substance use and poor treatment adherence leading to multiple readmissions for diabetic ketoacidosis, indwelling vascular catheter infections, and opioid overdose. The nephrostomy tube was ultimately removed 6 months after initial placement.

Emphysematous pyelitis is a gas‐forming infection of the renal pelvis with an estimated mortality of 20%. 1 This can be conflated with emphysematous pyelonephritis, which by contrast is a necrotizing infection with a mortality of 25%–42% characterized by air in the renal pelvis that extends to the parenchyma. 1 Emphysematous urinary tract infections are usually bacterial in origin, although fungal infections, such as in this patient, have been described. 2 , 3 , 4 Diabetes mellitus and urinary tract obstruction are the two major risk factors. 5 Mortality varies with severity of clinical presentation. 6 On ultrasound, gas in the kidney demonstrates a characteristic “dirty shadowing,” which can help to differentiate it from the more uniformly anechoic posterior acoustic shadowing of a similar appearing staghorn calculus. 7

CONFLICT OF INTEREST STATEMENT

M Prats has received payments from Butterfly Network, Inc. for consulting on educational materials. Advertising payments were made to M Prats' businesses Exo Imaging, Inc. and Echonous Inc.
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