Παθολόγος Κώστας Βαρδάκας

Patient with fever, weakness, anorexia and impaired communication


A 76-year-old gentleman with a history of diabetes mellitus under insulin, coronary artery disease (with stenting 8 years ago in myocardial infarction territory), heart failure, arterial hypertension, obesity, hyperlipidemia and nephrolithiasis She asked for our help because of a fever of 5 days that rose up to 38.5 °C but usually came down with simple antipyretics without reporting any other accompanying symptoms. The previous afternoon he had an episode of vomiting. The patient then consulted another doctor who recommended the use of oral antibiotics for a possible urinary tract infection. The patient started the antibiotics but the next morning he was found lying on the front doorstep of his house, weak, unable to get up and with impaired communication.


The clinical examination found fever (θ=38.4), 96 pulses and 34 breaths per minute and low blood oxygen (SO2 87%). The neurological examination did not reveal anything abnormal. However, the patient was unable to remember what had happened since he left home and his responses showed a very distressed person, as they were slow and disjointed. The lungs sounded normal except for mild acupuncture at the left base (he reported that all the doctors told him this), there was mild tenderness in the left abdomen, and there were no findings from the kidney examination. The rest of the clinical examination had no notable findings. After persistent questioning, the patient recalled that he had back pain that had worsened in the previous few days and that he had been losing blood in his urine for a long, but unspecified, period of time. Due to the severe picture, the patient was admitted to the hospital.


Blood and urine tests showed heavy, congested pyelonephritis with acute renal failure, dilated kidneys and nephrolithiasis and dysregulation of diabetes. Also there was anemia in the nature of blood loss. The patient was put on intravenous antibiotics and hydration with gradual improvement in clinical picture and renal function. A discussion with a urologist was held and immediate catheter placement for urinary drainage and removal of the stone was recommended at a later time. Due to the anaemia was transfusion with concentrated red blood cells. The patient refused further investigation of the anaemia and was discharged from hospital with oral antibiotics, but on re-examination after 4 days the fever had recurred. He was re-admitted to hospital and was again put on intravenous antibiotics. The fever subsided again but due to recurrent episodes immediate removal of the stone was recommended. A few days after surgery the patient was again discharged from hospital with oral antibiotics. On regular review the patient was in good condition with no fever and no symptoms.

The nephrolithiasis and diabetes are among the most important risk factors for the development of pyelonephritis. The stones act as foreign bodies that favour the establishment of microbes and diabetes reduces the body's defences. Although in this particular case the diagnosis of the first doctor was correct, a mistake was made in the treatment. Pyelonephritis in a man is by definition considered complicated, let alone when diabetes and nephrolithiasis coexist. Moreover, the presence of vomiting and the subsequent decrease in communication suggested a severe clinical picture requiring intravenous antibiotics from the beginning, which was confirmed by the severe laboratory findings. At the same time, this case highlights that severe infections in elderly patients often present with few or even no symptoms to guide the physician to the correct diagnosis.

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