2009 Volume 52 Issue 12 Pages 969-976
A 53-year-old woman with no significant medical history seen for general fatigue and appetite loss lasting several days had noticed asymptomatic gross hematuria two weeks earlier that had resolved immediately. Laboratory examination showed markedly elevated white blood cells, C-reactive protein, blood urea nitrogen, serum creatinine, plasma glucose, and ketone bodies. Acute renal failure with hyperkalemia and metabolic acidemia necessitated immediate continuous hemodiafiltration with continuous intravenous insulin infusion administration and antibiotic treatment. Klebsiella pneumoniae was isolated in both blood and urine culture on admission. Although her general condition gradually improved after admission, she continued to suffer from intermittent fever with pyuria. Abdominal computed tomography showed a diffusely enlarged left kidney with the normal parenchyma replaced by multiple low-attenuation masses. These typical imaging findings and clinical course yielded a definitive diagnosis of xanthogranulomatous pyelonephritis, considered refractory to conservative therapy for diffuse kidney involvement. Following total nephrectomy, postoperative histopathological findings were compatible with xanthogranulomatous pyelonephritis. Her renal function improved without postoperative hemodiafiltration support and fever and pyuria were resolved. This case is rare, demonstrating xanthogranulomatous pyelonephritis in a patient with undiagnosed diabetes, who suffered from diabetic ketoacidosis and acute renal failure requiring hemodiafiltration.
