A Diagnosis Hidden in Plain Sight: Pyelonephritis in the Setting of Ectopic Kidneys

Acute pyelonephritis often presents with the expected symptoms of flank pain and dysuria in the majority of patients suffering from this condition.  Pyelonephritis in patients with ectopic kidneys presents in a much more unique manner, often mimicking appendicitis or other intraabdominal disease processes, which can lead to a more difficult diagnosis.

 

Case Presentation:

A 24-year-old African-American female with a history of recurrent bacterial vaginosis and genital herpes presented with dysuria and generalized weakness that had been worsening for three days.  Associated symptoms included nausea, night sweats, emesis, and intractable lower abdominal pain.  On presentation she had a temperature of 104 and a heart rate of 110, prompting blood and urine cultures which resultantly grew e. coli.  Physical exam revealed pain to palpation of the lower abdomen and no flank pain.   CT was obtained which revealed inflammation surrounding the transverse colon with fat stranding adjacent to ectopically malrotated kidneys within the pelvis.  Patient was diagnosed with sepsis secondary to complicated pyelonephritis in the setting of ectopic pelvic kidneys and was treated with ceftriaxone with transition to oral ciprofloxacin at discharge to complete a total duration of 14 days. 

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Discussion:

Pyelonephritis in the setting of ectopic kidneys is a rare phenomenon but when present, can prove to be a challenging diagnosis given the atypical presentation.  Due to abnormal anatomy, there is often a finding of severe lower abdominal pain without any flank tenderness. This can be problematic as delays in diagnosis and treatment of pyelonephritis can lead to renal scarring, which may lead to residual hypertension and chronic renal disease (Lossius).  Over 50% of patients with ectopic kidneys have dilated collecting systems, which can predispose patients to an increased risk of developing pyelonephritis and the feared progression to sepsis (Lossius).  Our patient exhibited many of these signs and symptoms associated with pyelonephritis with ectopic kidneys and the decision to pursue abdominal and pelvic imaging proved paramount in making the diagnosis of pyelonephritis in this anatomical variant.

 

https://www-ncbi-nlm-nih-gov.pallas2.tcl.sc.edu/pmc/articles/PMC6865338/#ref2

 

https://www-ncbi-nlm-nih-gov.pallas2.tcl.sc.edu/pmc/articles/PMC2820289/