A 28-year-old male patient from the rural part of Bale zone, Ethiopia, was admitted to Goba Referral Hospital with high-grade fever, diffused abdominal pain and abdominal distension. He is a farmer and married with four children. The patient had experienced left flank pain for the past 6 years. Initially, he experienced colicky and intermittent pain that made him stay at home for 2-3 days. In addition, he had a history of reddish discoloration of urine during the flank pain episode. At the beginning of this condition, he did not visit any health care institution. He then started to develop constant left flank pain which gradually got worse and was associated with urinary frequency of around 5-6 times/day, high-grade intermittent fever, chills, rigors and loss of appetite. After 3 weeks of the abovementioned symptoms, he was admitted to Ginnir hospital (one of the rural hospitals in Ethiopia) for 7 days with the diagnosis of left pyelonephritis and was given ceftriaxone 1 g intravenous (IV) bid and diclofenac 75 mg intramuscular (im) and as needed (PRN). Despite this, after 6 days of stay in the aforementioned hospital, he developed generalized abdominal pain, abdominal distension, constipation and high-grade intermittent fever. Upon arrival to our hospital, Goba Referral Hospital, the patient was acutely sick looking and had a blood pressure (BP) of 80/50 mmHg, a pulse rate (PR) of 138 beats/minute, a respiratory rate (RR) of 34 breaths/minute and a temperature of 38.9 C. Besides, the patient had pink conjunctiva and dry tongue. He had clear chest on auscultation, and first heart sound or lub (S1) and second heart sound or dub (S2) were well heard when the heart was assessed. Regarding the abdominal assessment, his abdomen was distended, had no visible peristalsis, and it did not move with respiration. Also there was hypoactive bowel sound, guarding, rigidity, direct and rebound tenderness all over abdomen. The digital rectal examination showed empty rectum. He had a cold extremity. He had no history of diabetic mellitus, hypertension and he was neither a smoker nor an alcohol drinker. With the diagnosis of generalized peritonitis, we resuscitated him with two bags of normal saline and one bag of ringer lactate intravenously, causing his BP to became 100/60 mmHg. The laboratory investigation revealed the following: red blood cells, 201 g/dL; hemoglobin, 13.4 g/dL; white blood cells, 20,000/microL; granulocyte, 88%; platelet counts, 236,000/L; blood group, A+ and HIV antibody test, negative. In abdominal ultrasound examination, we identified that the left kidney was replaced by an abscess-containing sac, and there was huge intraperitoneal loculated abscess with internal septation and associated free inter-loop and pelvic echo debris abscess. After 2 hours of IV fluid administration, he produced 80 mL of urine. When we performed an exploratory laparotomy, 1 L-thick abscess from general peritoneum was aspirated, and early fibrinous inter-loop adhesion was identified. In addition, there was a huge retroperitoneal cystic abscess-containing sac extended from the spleen up to the pelvic brim crossing the midline to the right side and bulged intraperitoneally. Furthermore, about a 1.5 cm wide perforation that pour abscess in to peritoneal cavity was found. A total of 4 L of puss were removed out from the left kidney. As treatment, since the left kidney had lost full function (Figure 1) and became a pus-contacting sac, while the contralateral kidney was still normal, we performed a left-sided nephrectomy and abdominal lavage. When we mobilized the left colon during the intraoperative phase, adhesion and renal pedicle were identified. Therefore, double ligation of renal artery and vein together was done with silk number 1 as a result of inability to separate the renal artery and vein due to dense adhesion. Then, the ureter was ligated and divided. The abdominal wall was closed after the lavage drain was left inside. We did not find any stones in the affected kidney and nearby structure. Moreover, there was no evidence of tumor and tuberculosis from histopathologic examination of resected sample. Therefore, uretero-pelvic junction obstruction (UPJO) might be the possible cause of pyonephrosis of this case. Postoperatively, we put the patient on ceftriaxone 1 g IV bid, metronidazole 500 mg IV tid, maintenance fluid, tramadol 50 mg IV qid and diclofenac 50 mg im tid. He started sips on the third postoperative day. We removed the drain on the fifth postoperative day. The renal function test (RFT) performed in postoperative phase revealed normal range of serum electrolyte, and there was a normal amount of urine output. The patient had an uneventful recovery and was discharged from the hospital on the eighth day after surgery. We followed him for 6 months, and he had a normal kidney function test and did not develop any complications.
Written informed consent was obtained from the patient for publication of this case report.