A 28-year-old woman, second gravida, presented at 26 gestational weeks, with 20 day history of intermittent fever and generalized bodyaches, 2 months history of nocturia, and 1 month history of urinary urgency and frequency. She was treated locally with chloramphenicol and norfloxacin. She presented with septic shock and a presumptive diagnosis of acute pyelonephritis was made. The WBC total count was 26,000 (95% neutrophils, 5% lymphocytes), hemoglobin 7.5 g/dl, serum urea 154 mg/dl, serum creatinine 4.5 mg/dl, serum sodium 130 meq/l, serum potassium 5.5 meq/l, serum chloride 115 meq/l, and serum bicarbonate 7 meq/l. The arterial blood gas showed partially compensated metabolic acidosis (pH 7.05, HCO3 09 mmol, PCO2 21 mmHg, and PO2 112 mmHg).
The urine showed plenty of pus cells, and all her blood and urine cultures were sterile. Her ultrasonogram of the abdomen showed enlarged, heterogeneous appearing kidneys with hyperechoic renal pyramids suggestive of medullary nephrocalcinosis [Figure 1] with no perinephric stranding. There was no evidence of hydronephrosis or calculus. She was empirically treated with meropenem 500 mg IV once daily and vancomycin 1 g IV once in 5 days. She remained febrile even after 72 h of antibiotics, and her urine and blood grew no organism. Injection amikacin was added after appropriate dose modification. She received four sessions of hemodialysis over 5 days for her severe renal failure and severe metabolic acidosis. He renal function rapidly improved by the end of 1 week and she became afebrile 48 h after adding amikacin. Amikacin was discontinued after 7 days due to fear of fetal ototoxicity, and meropenem and vancomycin were stopped after 10 days by which time her serum creatinine had improved to 1.8 mg/dl. Her fetus showed normal growth for the gestational age and she was discharged to come after 2 weeks with repeat urine culture and follow-up. Four days before her planned visit, she had developed bilateral loin pain. There was left renal angle tenderness and firm palpable swelling was noticed locally. Ultrasound showed bilateral perinephric collection with left psoas abscess and MRI scan showed significant bilateral psoas and perinephric abscesses [Figure 2]. A 10 F pigtail catheter was inserted in both the psoas abscesses. The "milk-coffee" colored pus showed 3+ acid fast bacilli (AFB) and culture grew E. coli, and there was a delayed growth of Enterococcus sp. The same organisms were isolated in repeated sampling on both sides. HIV was negative and her CD3 count was also within normal limits. Her corrected serum calcium and magnesium were 9.4 g/dl and 1.8 mg/dl, respectively, and her parathormone level was 71 ng/ml, low for her level of renal function. Her 24-h urine calcium was 112 mg/day and her urine calcium creatinine ratio was 0.12.
The patient was started on isoniazid, rifampicin, ethambutol, pyrazinamide, and pyridoxine for TB, and Inj. piperacillin and tazobactum for E. coli and ampicillin for Enterococci as per the antibiotic sensitivity. She developed oligohydraminos and intrauterine growth retardation during treatment. At 34 weeks, she developed labor pain spontaneously and delivered a 1.54-kg male baby. The child was given Bacillus Calmette-Guerin (BCG) vaccination and isoniazid prophylaxis. There was no relapse of psoas abscess 1 month after removal of both her pigtail catheters. Her renal function, which was stable, worsened after pigtail catheter insertion and after starting of ATT. The serum creatinine rose from 1.4 mg/dl to 1.9 mg/dl. No cause was identified and no change in therapy was made. Her renal function improved after 10 days to 1.2 mg/dl at the time of her delivery without any change in her medications. Four months after discharge, the serum creatinine improved to 0.8 mg/dl and the ultrasound showed no evidence of nephrocalcinosis.