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.

As with our patient, when large portions of the cranium have been removed by operation, external injury, or exfoliation, the brain is deprived of its support, and, by the pulsation of its arteries, the dura matter is rubbed against the rough edges of the bone, by which it ulcerates, and the brain then protrudes. This protrusion from the cerebrum is more particularly apt to occur when the dura matter has been wounded by accident or design and it may present  itself under three different forms: It may consist either of disorganized pure cerebral matter, partly of cerebral matter and of coagulated blood; or be an organized mass.

The first generally occurs immediately after the injury, and arises from the substance of the brain being wounded, and a portion of it being separated from the common mass.

The second most commonly takes place some days after the injury, and seems to arise from the rupture of one or more blood vessels a little below the surface of the brain, in consequence of which, a portion of this viscus is mechanically raised through the opening in the dura matter, skull, and integuments. This protrusion is of a dark color and is at first covered by the pia matter, but the internal hemorrhage continuing, the brain is still farther raised. This membrane then gives way. At length, the the brain yields and the blood is effused upon the surface of the tumor.

The third species of protrusion from the brain follows abscess or ulceration of that organ, hence does not appear for many days, and is as completely organized as the fungi springing from other ulcers. The fungus which arises from the brain shoots up with great rapidity, is of a greyish colour, and is generally about the size of a pigeon’s head, but, on some occasions, it is as large as a hen’s egg or a small orange. Its appearance is always preceded by an opening in the dura matter and is always connected with ulceration of the brain.

External herniations, also known as fungus cerbrei, are the rarest of the acquired herniations. They are most frequently caused by post surgical and post traumatic defects that allow swollen or displaced brain to pass through. This type of herniation may be beneficial by relieving intracranial pressure and thereby preventing more devastating complications due to internal herniation; however; external exposure of the brain can result in infections, complications, and many of these patients have a poor prognosis because of  the severity of their underlying illness. Both CT and MR imaging are effective at demonstrating these herniations. MR imaging, however, is clearly superior at defining soft tissue, which can be critical in certain clinical scenarios. Distingushing brain tissue from other tissues such as granulation tissue, cholesteatoma, tumor, or other lesions involving defects of the skull is essential and MR imaging accomplishes this well.

Observation

Clinical History: bleed, follow up

Technique: CT scan of the head without intravenous contrast

Compared with prior study dated January 30, 2010

The presence of streak artifact limits the study. There is interval development of some degree of herniation of the left frontal lobe through the left craniectomy defect with interval development of subdural hygroma in the right frontoparietal convexity and evolution of the previously noted mild left to right subfalcine herniation into a mild degree of right to left subfalcine herniation. There is partial interval improvement of the pneumocephalus in the left frontal and left parietal convexities. There is no significant interval change in the left frontotemporoparietal, parafalcine, and left paratentorial hyperdensities, which may reflect subdural hemorrhage. There is interval development of opacities in some of the ethmoid air cells and sphenoid sinuses.

Impression

INTERVAL DEVELOPMENT OF SOME DEGREE OF HERNIATION OF THE LEFT FRONTAL LOBE THROUGH THE LEFT CRANIECTOMY DEFECT. CONSISTENT WITH DEVELOPMENT OF POST-SURGICAL PSEUDOENCEPHALOCELE (FUNGUS CEREBRI). ASSOCIATED INTERVAL DEVELOPMENT OF RIGHT-SIDED SUBDURAL HYGROMA AND MILD RIGHT TO LEFT SHIFT. NO SIGNIFICANT INTERVAL CHANGE IN THE LEFT FRONTOTEMPOROPARIETAL, PARAFALCINE, AND LEFT PARATENTORIAL HYPERDENSITIES, MAY REFLECT SUBDURAL HEMORRHAGE. INTERVAL DEVELOPMENT OF OPACITIES IN THE ETHMOID AND SPHENOID SINUSES, SUGGESTIVE OF SINUSITIS. PARTIAL INTERVAL IMPROVEMENT OF THE PNEUMOCEPHALUS IN THE LEFT FRONTAL AND LEFT PARIETAL CONVEXITIES.