Pyelo-hepatic abscess caused by renal calculi: A rare complication
A 25-year-old lady presented to the urological emergency with complaint of episodes of dull aching colicky pain in the right lumbar region for the past 1 year, which had increased in severity and become continuous for the past 2 weeks. Pain was associated with fever, chills, nausea, and anorexia. She also reported weakness and malaise, but did not give any history of urinary or bowel complaints. Physical examination revealed a pulse rate of 104/min, low blood pressure of 104/60 mm of Hg, respiratory rate of 22/min, and a temperature of 101°F. There was tenderness in the right hypochondrium and the right renal angle, but no visible fullness. Keeping a differential diagnosis of gall stone disease and pyonephrosis, an urgent ultrasound examination was done which showed grade III dilatation of the right kidney with internal echoes and multiple calculi, largest of size 18 mm, located in the pelvis. The liver showed a hypoechoic lesion of 10 × 10.2 cm in the right lobe. A breach in the renal capsule was demonstrated, communicating with the lesion in the liver. Laboratory investigations revealed marked leukocytosis, severe anemia (5.5 g/dl), mildly deranged renal function (blood urea 60 mg/dl, serum creatinine 1.6 mg/dl) and coagulopathy (International Normalised Ratio 1.63). Based on a working diagnosis of pyonephrosis with liver abscess with septicemia, the patient was resuscitated with fluids and given intravenous antibiotics and blood transfusion. Dehydration and coagulopathy were corrected and a contrast-enhanced computed tomography (CT) was obtained, revealing a hypodense peripherally enhancing lesion with air in the right lobe of the liver communicating with the upper calyx of the hydronephrotic right kidney with multiple calculi []. The function of the left kidney was normal as evident by normal contrast excretion. Right pleural effusion with consolidation of the right lower lobe of the lung was also seen. The patient's condition improved on antibiotics, and right DJ stenting was performed along with an ultrasound-guided drainage of 800 ml pus from the right lobe of the liver. Culture of both urine and pus grew Escherichia coli, sensitive to amikacin. She responded well to treatment and was discharged with a plan for right Percutaneous Nephrolithotomy after 6 weeks. On subsequent follow-up visits, ultrasonography showed minimal abscess in the liver.