Case Study: Acute Pyelonephritis with Obstructing Infected Ureteric Stone Causing Urosepsis in a Female

Abstract

This case describes a rapidly progressive urinary tract infection complicated by an obstructing ureteric calculus, leading to acute pyelonephritis and urosepsis in a middle-aged female. Early recognition of systemic deterioration, prompt imaging, emergency drainage, and targeted antimicrobial therapy were essential to prevent multiorgan involvement. The case highlights the importance of rapid intervention when infection coexists with obstruction, as delayed management greatly increases morbidity and mortality.

Introduction

Obstructive uropathy combined with infection represents one of the most dangerous urological emergencies. Ureteric stones that cause urinary stasis provide a favorable environment for bacterial proliferation, potentially leading to pyelonephritis and subsequent urosepsis. Middle-aged women, especially those with recurrent UTIs or metabolic stone disease, are at increased risk. Early diagnosis and urgent decompression of the renal system are critical to prevent septic shock.

Patient Information

A 46-year-old female presented to the emergency department with a three-day history of progressive right flank pain, fever, chills, and nausea. She reported dysuria and reduced urine output over the past 24 hours. Past medical history included recurrent urinary tract infections and a previous episode of renal colic two years prior. No history of diabetes or immunosuppression was noted.

Clinical Findings

On arrival, the patient appeared acutely ill. Her temperature was 39.4°C, blood pressure 92/56 mmHg, heart rate 122 beats per minute, and respiratory rate 26 breaths per minute. She displayed costovertebral angle tenderness on the right side and mild suprapubic discomfort. Capillary refill was delayed, and mucous membranes were dry, suggesting early circulatory compromise.

Timeline

Symptoms started three days prior with flank pain and dysuria. Over the next 48 hours, fever escalated and urine output dropped. On day three, she developed chills, lethargy, and dizziness, prompting hospital presentation. Within hours of arrival, blood pressure further decreased, meeting criteria for sepsis.

Diagnostic Assessment

Laboratory tests revealed leukocytosis with neutrophilic predominance, elevated C-reactive protein, and markedly raised serum creatinine indicating acute kidney injury. Urinalysis showed pyuria, bacteriuria, and positive nitrites. Blood cultures and urine cultures were drawn before antibiotics. A contrast-enhanced CT scan of the abdomen and pelvis revealed a 9 mm obstructing stone at the right proximal ureter with moderate hydronephrosis and perinephric fat stranding, confirming acute pyelonephritis with obstruction.

Differential Diagnosis

Renal colic without infection
Acute pyelonephritis without obstruction
Ureteric stricture with secondary infection
Renal abscess
Urosepsis secondary to lower tract infection

Therapeutic Intervention

Given the combination of infection and obstruction, the patient required urgent renal decompression. Broad-spectrum intravenous antibiotics were initiated immediately after cultures were taken. Due to her hemodynamic instability, the urology team performed emergency percutaneous nephrostomy under ultrasound guidance to relieve the obstruction. Intravenous fluids and vasopressor support were started to manage septic physiology. After stabilization, antibiotic therapy was adjusted based on culture results, which grew Escherichia coli sensitive to third-generation cephalosporins.

Challenges Faced

The primary challenge was the patient's rapid progression to sepsis, with declining blood pressure and early organ dysfunction. Her acute kidney injury complicated drug dosing and fluid management. Performing interventional procedures in a hemodynamically unstable patient required close coordination between the critical care and urology teams. Delayed presentation increased the severity of infection.

Follow-Up and Outcomes

Within 48 hours of nephrostomy insertion and targeted antibiotics, the patient showed significant clinical improvement. Fever subsided, urine output increased, and inflammatory markers declined. Kidney function gradually recovered. After seven days of hospitalization, she was stable enough for discharge with oral antibiotics. Four weeks later, a definitive ureteroscopic laser lithotripsy was performed to remove the stone, followed by nephrostomy removal. Long-term follow-up showed full recovery without recurrent infections.

Discussion

This case illustrates in detail the life-threatening nature of infected obstructing ureteric stones and reinforces the critical need for rapid, well-coordinated intervention. When urinary obstruction and infection occur simultaneously, the renal collecting system becomes a high-pressure, closed environment that fosters explosive bacterial proliferation. In this setting, bacteria and inflammatory toxins can quickly translocate into the bloodstream, accelerating the progression from localized infection to systemic inflammatory response, septic shock, and multi-organ dysfunction. Such a pathophysiologic cascade can unfold within hours, making timely recognition essential for patient survival.

Cross-sectional imaging especially contrast-enhanced or non-contrast CT scanning, remains the gold standard for diagnosing both the obstructing calculus and associated complications such as perinephric stranding, hydronephrosis, or gas-forming infections. CT findings guide clinicians in promptly selecting the appropriate decompression strategy. Emergency drainage of the obstructed system, whether through retrograde ureteral stenting or percutaneous nephrostomy, is universally recognized as the cornerstone of management. Importantly, antimicrobial therapy alone is insufficient in the presence of obstruction, as the infected urine cannot adequately drain and continues to fuel sepsis despite systemic antibiotics.

Early multidisciplinary involvement—including urology, emergency medicine, radiology, nephrology, and intensive care—has been shown to significantly improve clinical outcomes. Rapid triage, coordinated imaging, immediate decompression, hemodynamic stabilization, and targeted antibiotic therapy are vital steps, particularly in patients presenting with severe sepsis, acute kidney injury, immunosuppression, or delayed diagnosis. This case reinforces the critical principle that infected obstruction is not simply a urological issue but a complex medical emergency where swift, integrated action can be the difference between survival and irreversible organ damage.

Multidisciplinary Approach

The coordinated involvement of emergency physicians, radiologists, critical care specialists, and urologists ensured rapid diagnosis and stabilization. Critical care support was essential for managing septic shock, while interventional radiology and urology collaborated to provide timely decompression. Follow-up by nephrology helped guide renal recovery and prevent long-term damage.

Key Takeaways

Infection with obstruction is a urological emergency
Rapid imaging and immediate decompression are essential
Delay increases the risk of septic shock and organ failure
Culture-guided antibiotics enhance recovery
Multidisciplinary care is crucial for septic patients

Patient’s Perspective

The patient reported that flank pain and fever were initially manageable, causing her to delay care, but rapid deterioration frightened her. She felt relief shortly after the nephrostomy and was grateful for the clarity provided about her condition and long-term preventive strategies. She now actively increases hydration and adheres to dietary modifications to reduce future stone risk.

Conclusion

Acute pyelonephritis with an infected obstructing ureteric stone represents one of the most urgent and life-threatening conditions in clinical urology, requiring immediate diagnostic evaluation and rapid therapeutic action. The combination of urinary tract infection with mechanical obstruction creates a closed, high-pressure environment in which bacteria replicate quickly, allowing toxins and inflammatory mediators to spill into the bloodstream. Without swift recognition and intervention, patients can progress to septic shock, multiorgan dysfunction, and irreversible renal damage within hours. Early symptoms may appear nonspecific, but escalating fever, flank pain, rigors, vomiting, and reduced urine output should prompt immediate suspicion of obstructive pyelonephritis.

Timely recognition, prompt decompression, aggressive antimicrobial therapy, and comprehensive supportive care form the cornerstone of management in such cases. Emergency imaging helps confirm the site and severity of obstruction, while rapid decompression through ureteral stenting or percutaneous nephrostomy is essential to relieve backpressure, drain infected urine, and stabilize the patient. Antibiotics alone are insufficient when obstruction persists, making source control the most critical determinant of survival. Once the urinary system is decompressed, culture-guided antibiotics, hemodynamic monitoring, intravenous fluids, and vasopressor support (when necessary) help reverse septic physiology.

Equally important is the multidisciplinary coordination between emergency physicians, urologists, interventional radiologists, and critical care teams. Their combined efforts allow for rapid diagnosis, safe procedural intervention, and careful postoperative monitoring. Continuous follow-up of renal function, electrolyte balance, and infection markers helps detect complications early and ensures full recovery. This case demonstrates how early intervention and unified teamwork significantly improve outcomes, even in patients presenting with severe sepsis or delayed diagnosis. Rapid treatment not only preserves kidney function but also reduces mortality, reinforces the value of early medical attention, and highlights the importance of patient education regarding warning signs of urinary obstruction and infection.

References

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