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An Elderly Nursing Home Patient
with a Cryptic Source of Sepsis

Daniel A. Sweeney, MD
Attending Physician
Washington Hospital
Fremont, CA 94538

History of present illness: A 55 year old woman presents from a skilled nursing facility with nausea and vomiting.

Past Medical History: CVA and aspiration pneumonia

Vital signs: BP 85/40 mmHg; pulse 135/min; Respiratory rate 20/min; pulse oximetry 94% on 2L NC; temperature 101.3°F

Physical Examination: opens eyes to touch, nonverbal, does not follow commands; decreased breath sounds over lower chest bilaterally on anterior exam

EKG: sinus tachycardia

Initial labs:  WBC- 42 x 103/µL; Creatinine- 1.6 mg/dl; lactate concentration 5.2 mmol/L. urinalysis: specific gravity 1.025; nitrite negative; leukocyte esterase positive; RBCs 20-30/hpf; WBCs 15-25/hpf

Imaging: A CT head revealed no acute disease.  CXR was reported as “bibasilar atelectasis versus infiltrates, clinical correlation recommended.”

Point-of-care abdominal sonography is performed and the following representative image is obtained by examining the left flank.

sweeney-hydronephrosis

Question:  What is the most likely source of sepsis in this patient?

Hydronephrosis

This ultrasound image the left kidney in the longitudinal axis reveals hydronephrosis and hydroureter. 

The primary indication for bedside sonography of the kidney is to determine whether hydronephrosis is present (1).Normally, the kidney sinus (consisting of the renal pelvis and calyces) contains fat and is therefore hyperechoic and the ureter is not visualized (see video below).  Depending upon the degree of hydronephrosis (mild, moderate or severe) the sinus becomes increasingly hypoechoic and the ureter may be visibly dilated.

There is debate in the literature regarding whether point-of-care clinicians can accurately identify hydronephrosis (2).  Nonetheless, in cases of renal failure, hematuria, abdominal pain and sepsis it is reasonable to perform such an exam.  In this particular patient, there were multiple possible sites of infection.  Bedside ultrasound resulted in the prompt identification of the source of sepsis and subsequent placement of a nephrostomy tube early in the patient’s hospital course.

sweeney-normal-kidney-labeled

sweeney-hydronephrosis-labeled

References:

  1. Nilam J. Soni RA, and Pierre Kory. Point of Care Ultrasound. Philadelphia, PA: Elsevier; 2014.
  2. Herbst MK, Rosenberg G, Daniels B, Gross CP, Singh D, Molinaro AM, Luty S, Moore CL. Effect of provider experience on clinician-performed ultrasonography for hydronephrosis in patients with suspected renal colic. Annals of emergency medicine 2014; 64: 269-276.

06/2015