CT hypoperfusion complex from pyelonephritis

Case contributed by Jeremy Lim


Hypotensive, shock. ?perforation ?bleed

Patient Data

Age: 35 years
Gender: Female

Numerous signs of shock/visceral hypoperfusion:

  • bilateral hyperenhancing adrenal glands
  • hyperenhancing, thickened small bowel mucosa
  • mottled enhancement of the liver and spleen on portal venous phase, which becomes homogeneous on delayed phase
  • gallbladder wall thickening

Surprisingly, the IVC is round rather than flattened due to ongoing fluid resuscitation. Periportal edema and pericholecystic free fluid. Small volume of right retroperitoneal fluid.

Asymmetric enhancement of the kidneys, less on the right with multiple peripheral wedge-shaped regions of reduced/non-enhancement. Multiple tiny bilateral non-obstructive renal calculi. No ureteric calculi. No hydronephrosis. Incidental note of double right renal veins and retro-aortic left renal vein.

Case Discussion

Presented hypotensive requiring fluid resuscitation and blood transfusion. Surgical team concerned re:active bleed or perforated viscus.

On further questioning (after the scan), the patient reported back pain, fevers and vomiting in the previous 2 days. Hematuria present.

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