Lobar nephronia

Abstract

A 7-year-old female had a fever to 41.0°C with shaking chills and vomiting three days before admission. Two weeks previously, she had had a fever of 40.6°C lasting 8 days. There was a past history of right sided Grade IV vesicoureteral reflux and duplicated renal collecting system diagnosed after a urinary tract infection. After some time on prophylactic antibiotics, a follow up voiding cystourethrogram showed no reflux. On physical examination, the patient had a temperature of 40.7°C and mild renal angle tenderness on the right side. The CBC showed a WBC count of 25.6 x 103/cmm (89% neutrophils). Urine culture grew only 3000 enterococcus/ml. The patient did not have any clinical manifestations of disorders that may be found in patients with fever of unknown origin. There were two negative urine cultures, negative chest x-ray and sinus x-ray. There was no reason to think she might have endocarditis, cat scratch disease, inflammatory bowel disease, Kawasaki's disease or juvenile rheumatoid arthritis. A sonogram of the kidneys offered a suspicion that something was not quite right, a CAT scan did not help in this case but an MRI defined in great detail an area of pyelonephritis in the right kidney. A DMSA scan supported this finding by showing a defect in the right kidney most consistent with an acute infection. This patient dearly had an upper tract infection that was not communicating with the urinary tract. This was considered to be acute focal pyelonephritis, called lobar nephronia in the past. The patient responded well to intravenous antibiotic treatment.