Fast Five Quiz: Are You Prepared to Confront Pyelonephritis?

Vecihi Batuman, MD


February 26, 2018

The classic presentation in acute pyelonephritis is the triad of fever, costovertebral angle pain, and nausea and/or vomiting. These may not all be present, however, or they may not occur together temporally. Symptoms may be minimal to severe and usually develop over hours or over the course of a day. Infrequently, symptoms develop over several days and may even be present for a few weeks before the patient seeks medical care. Symptoms of cystitis may or may not be present to varying degrees. These may include urinary frequency, hesitancy, lower abdominal pain, and urgency.

A history of the following indicates an increased risk for complicated pyelonephritis:

  • Structural abnormalities of the urinary tract

  • Functional abnormalities of the urinary tract

  • Metabolic abnormalities (ie, poorly controlled diabetes) predisposing to urinary tract infections (UTIs)

  • Recent antibiotic use

  • Recent urinary tract instrumentation

  • Transplant status or other immunocompromised state

  • Pregnancy

The presence of any one of the above complicating factors should raise the clinician's index of suspicion. In many instances, more than one complicating factor is involved. In addition, if the patient is male, elderly, or a child or has had symptoms for more than 7 days, the infection should be considered complicated until proven otherwise.

The classic signs and symptoms observed in adults are often absent in children, particularly neonates and infants. In children 2 years of age and younger, the most common symptoms of UTIs are failure to thrive, feeding difficulty, fever, and vomiting. When fever is present, pyelonephritis should be in the differential diagnosis.

Gross hematuria (hemorrhagic cystitis) is present in 30%-40% of pyelonephritis cases in females, most often young women. Gross hematuria is unusual in males and should prompt consideration of a more serious cause.

For more on the presentation of acute pyelonephritis, read here.


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