Textbook case of Emphysematous pyelonephritis, which is incredibly rare these days given the super strong antibiotics available…

Observation

Clinical history: Rule out PE, chills, elevated D-dimer

Technique: CT scan of the chest and bilateral lower extremity venogram with intravenous contrast

No CT features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by a suboptimal bolus of contrast and small peripheral emboli cannot be entirely excluded. The pulmonary arteries are prominent, suggesting an element of possible pulmonary arterial hypertension. Calcified granulomas are noted in the lungs bilaterally. No pleural effusion or pneumothorax is seen. No pericardial effusion is seen. Mild cardiomegaly is noted. Calcified right hilar lymph nodes are noted. The aorta is unremarkable without aneurysm or dissection. Degenerative changes of the spine are noted. The left kidney is severely enlarged with severe hydronephrosis and significant cortical thinning. There are air fluid levels within the left kidney, suggestive of emphysematous pyelonephritis. There is an approximately 9 cm diameter abscess off the upper pole of the left kidney centered on approximately image 163 which at its lower aspect on image number 165 appears to necessitate through the renal capsule and extend through left lateral abdominal wall possibly involving the lateral extra peritoneal abdominal wall musculature. There is a second large abscess which appears to extend from a left medial inferior renal calyx to involve the psoas muscle. This also has associated gas within it consistent with a large abscess necessitating from the kidney to the psoas muscle. A few small bowel loops are prominent, likely representing ileus. Bilateral lower extremity veins are well opacified. No filling defect is noted to suggest deep vein thrombosis.

Impression

Chest CT impression: No Ct features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by suboptimal bolus of contrast as well as breathing motion artifact and small peripheral emboli cannot be excluded. Correlate clinically. Consider further evaluation with nuclear medicine ventilation perfusion scan.

Abdominal CT report: severe emphysematous pyelonephritis with two large abscess is one which necessitates to the lateral abdominal wall likely extending into the extra peritoneal deep muscle layer. A second appears to necessitate from the lower medial renal calyx to involve the psoas muscle. Follow up recommended. No CT features of deep vein thrombosis.