A Case of left Flank Pain

A 48-year-old woman presented to the emergency department with three days of fever, along with rigors, left flank pain and oliguria. She had diabetic nephropathy with a baseline serum creatinine level of 247.5 (normal < 133) µmol/L and an estimated glomerular filtration rate of 19 (normal 91–130) mL/min/1.73m2. The patient’s temperature was 38.8°C, blood pressure was 139/73 mm Hg and she had tenderness at the left costovertebral angle.
Laboratory studies revealed a hemoglobin concentration of 90 (normal 120–160) g/L, leukocyte count 31.48 (normal 4.3–10.8) x 109/L, platelet count 296 (normal 130–400) x 109/L and hemoglobin A1C of 8.5%. Serum creatinine was 530.4 (normal < 133) µmol/L and urinalysis showed 5–10 white blood cells per high-power field. A plain radiograph showed a rosette-like arrangement of gas in the collecting system of the patient’s left kidney and upper ureter . An unenhanced computed tomography (CT) scan of the abdomen showed air in the dilated renal calyces, pelvis and upper ureter . No evidence of urinary tract obstruction was found. The patient was diagnosed with emphysematous pyelitis. Peripheral blood and urine cultures grew Escherichia coli, sensitive to ceftriaxone. (A) Plain radiograph of a 48-year-old woman showing rosette-like arrangement of gas in the collecting system of her left kidney (white arrows) and upper ureter (black arrow). (B) Coronal view of an abdominal computed tomography scan showing air in the dilated renal calyces, pelvis and upper ureter (white arrows). A tiny renal stone (black arrow) is present.

Treatment with nephrostomy and intravenous ceftriaxone 2 g daily led to clinical and radiological improvement. On follow-up at three weeks, the patient’s creatinine level was 265.2 µmol/L and estimated glomerular filtration rate 18 mL/min/1.73m2.

What we learned??

1. Emphysematous pyelonephritis occurs more commonly in middle-aged women with poorly controlled diabetes or urinary tract obstruction. It should be considered in patients with pyelonephritis who develop thrombocytopenia, acute renal failure, reduced level of consciousness or shock. These factors also contribute to increased mortality.
2. Escherichia coli is the most common organism found in emphysematous pyelonephritis, followed by Klebsiella pneumoniae.
3. Ultrasonography with plain radiography is recommended in all patients with diabetes who have acute pyelonephritis. Imaging is not generally recommended in patients who are otherwise well who respond to therapy within 72 hours.
4. Computed tomography is the most sensitive method to demonstrate gas within and adjacent to the kidney.
5. The initial management of emphysematous pyelonephritis includes resuscitation, antibiotic treatment targeting Gram-negative bacteria and control of diabetes if present.
6. Most patients require nephrostomy. Emphysematous pyelitis has an excellent prognosis with prompt diagnosis and treatment.

Acne Vulgaris

Acne vulgaris is a common skin disease that affects 60-70% of Americans at some time during their lives. Twenty percent will have severe acne, which results in permanent physical and mental scarring. Acne vulgaris is American's most common disease and is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules. Acne vulgaris affects the areas of skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back.

Acne vulgaris is characterized by comedones, papules, pustules, and nodules in a sebaceous gland distribution. A comedone is a whitehead (closed comedone) or a blackhead (open comedone) without any clinical signs of inflammation. Papules and pustules are raised bumps with obvious inflammation. The face may be the only involved skin surface, but the chest, back, and upper arms are often involved.

* In comedonal acne, no inflammatory lesions are present. Comedonal lesions are the earliest lesions of acne, and closed comedones are the precursor lesion of inflammatory lesions.


Acne, grade I; multiple open comedones.

* Mild acne is characterized by comedones and a few papulopustules.


Acne, grade II; closed comedones.

* Moderate acne has comedones, inflammatory papules, and pustules. Greater numbers of lesions are present than in milder inflammatory acne.
Acne, grade III; papulopustules.

* Nodulocystic acne is characterized by comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter. Scarring is often evident.
Acne, grade IV; multiple open comedones, closed comedones, and papulopustules, plus cysts.

Markel sign in heel jar test ,and others!!

Abdominal pain upon vibration (the heel jar test) is commonly known as which of the following?

• a.Markel sign
• b.Blumberg sign
• c.Rovsing sign
• d.Obturator sign
• e.Iliopsoas sign
• f.Courvoisier sign
• g.Dance sign

The answer is (a).
The Markel sign(which is a maneuver to detect peritoneal irritation) is tested by the heel jar test; the patient stands on his or her toes, then allows his or her heels to hit the floor, thus jarring the body and causing abdominal pain in peritonitis.
The Rovsing sign occurs when palpation of the LLQ causes pain in the RLQ.
The obturator sign is pain occurring when the bent leg is rotated laterally and medially.
The iliopsoas sign occurs when the patient tries to raise the leg up against the hand of the examiner pushing down against the leg above the knee.

-The Markel sign,obturator sign, iliopsoas sign, and Rovsing sign are seen in appendicitis. A patient with appendicitis may also have pain on rectal examination if the posterior appendix is involved.

The Courvoisier sign is a palpable nontender gallbladder, which suggests neoplasm.
The Dance sign is the absence of bowel sounds in the RLQ due to intussusception

64 Slice CT Scanner

Ochsner's 64 Slice Computed Tomography scan helps physicians diagnose and pinpoint heart attacks and strokes. Unlike an angiogram, the 64 slice CT Scan is non-invasive.

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Ancient Egyptians treated Bitot Spots

Bitot spots are an example of an eye manifestation of a systemic disease. They are superficial, irregularly-shaped, foamy gray or white patches that appear on the conjunctiva, the membrane that covers most of the eyeball.


Bitot spots are one of the oldest recorded medical conditions. The ancient Egyptians treated this condition with animal liver more than 3500 years ago. Composed of accumulation of keratinized epithelial debris and secretions, Bitot spots develop into xerophthalmia if not treated. Bitot spots are usually accompanied by ...............

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Viva Voce Orals in Biochemistry

The idea of writing this book of VIVA VOCE/ORALS IN BIOCHEMISTRY is that it should bemuch helpful to the MBBS and M.Sc. (Medical Science) students and post-graduate students for thepreparation of examination. Though it is not a textbook of medical Biochemistry, it is framed in theform of questions and answers in a simplified way. This book will definitely help the students for thepreparation of their examinations.This book is also aimed at the level of general practitioners, clinicians and medical students andtechnicians for applying the knowledge of clinical biochemistry in the clinical side, as much emphasisis given in the clinical biochemistry. The list of clinical biochemistry topics include interpretation oflaboratory data and biochemical features of some clinical diseases like metabolic syndrome, diabetesmellitus, anaemias, jaundice, porphyrias and the disturbances of electrolyte and acid base balance.

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