Successfully Treated Escherichia coli-Induced Emphysematous Cyst Infection with Combination of Intravenous Antibiotics and Intracystic Antibiotics Irrigation in a Patient with Autosomal Dominant Polycystic Kidney Disease
A 62-yr-old female ADPKD patient was admitted to our hospital for further evaluation of intermittent fever, nausea and left flank discomfort on April 26, 2012. The patient had a 15-yr-history of ADPKD that was detected when the patient was diagnosed with hypertension. Her two brothers also were diagnosed as ADPKD. However, the patient had no history of diabetes. The patient had been examined for ADPKD at our outpatient clinic since 2004. Despite a history of recurrent cyst hemorrhage, the patient achieved a full recovery from the hemorrhage with conservative management. In 2009, the patient was admitted for the treatment of suspicious cyst infection versus acute pyelonephritis. She received ciprofloxacin for the infection and had E. coli detected in the urine culture. Her renal function deteriorated progressively thereafter to begin hemodialysis from April 2011. Her daily urine output remained about 200 cc.\nTwo months before the current outpatient visit, she felt generalized weakness, anorexia, nausea and the discomfort in the left flank. She also developed intermittent fever with chilling sense one month prior to the visit. Therefore, the patient visited an emergency care center at the outside hospital to take CT scan which revealed about 8.1-cm large gas-forming cyst at the left kidney lower pole (). Her initial laboratory findings showed WBC counts of 22,190/µL and CRP of 25.5 mg/dL. The urinary sediment contained numerous RBCs and WBCs per high power field. Despite a 1-week course of intravenous antibiotic therapy with ciprofloxacin, her fever and flank discomfort persisted and subsequently resulted in general weakness and anorexia. The patient was referred to our clinic for further treatment plan including left nephrectomy. On admission, the patient had the temperature 38.4℃ and the blood pressure was measured as 150/85 mmHg. On physical examination, the patient showed local tenderness in the left flank. However, there was no definite presence of the costovertebral angle tenderness.\nOn clinical laboratory findings, the patient had WBC counts 12,850/µL, hemoglobin 9.7 g/dL, platelet counts 348,000/µL, blood urea nitrogen 39 mg/dL, creatinine 7.76 mg/dL, albumin 3.3 mg/dL, CRP 6.79 mg/dL. The urinary sediment contained numerous RBCs and WBCs per high power field. Although her laboratory parameters partially improved after a 1-week course of intravenous antibiotic therapy, her symptoms did not improve. Therefore, she was determined to undergo percutaneous cystostomy drainage of a large gas-forming cyst. The cyst was aspirated under ultrasound guidance followed by the percutaneous cystostomy drainage on hospitalization day 2. On clinical laboratory tests, cyst aspiration had RBC counts 290,000/µL and WBC counts 180,000/µL (polymorphonuclear leukocytes 98%, lymphocytes 0% and others 2%). In addition, a gram-stain revealed many ( > 10) WBCs and many ( > 10) G(-) rods. Finally, a culture of the cyst aspirate yielded E. coli, but the blood and urine culture were negative.\nThe patient was started on intravenous ciprofloxacin at a daily dose of 400 mg for 1 week. This was followed by an intracystic irrigation of ciprofloxacin through a percutaneous cystostomy drainage for 6 days. For the intracystic irrigation, 100 mg (50 cc) of ciprofloxacin was mixed with 450 cc of normal saline.Then repeated irrigation with the antibiotics mixture was performed. Following the treatment, the symptoms such as generalized weakness, nausea and discomfort in the left flank improved. This was also accompanied with the normalization of laboratory parameters.\nFollowing intravenous antibiotic therapy and intracystic antibiotic irrigation, the patient had the percutaneous cystostomy drainage removed. Her following CT scans showed decreased size of the infected cyst (8.1 to 4.7 cm) with internal mottled air attenuation (). The patient was discharged with oral ciprofloxacin for 6 more weeks.