Presentation
Acute onset of bilateral flank pain, hematuria with rigors and fever. Known diabetes mellitus.
Patient Data
Multiphasic CT imaging demonstrates heterogenous enhancement of the kidneys bilaterally (cortical and parenchymal phase) and multiple filling defects on the delayed phase within the left calyceal system. There is calyceal blunting of the right kidney. There is minimal left peri-nephric stranding. There is a solitary punctate non-obstructing calculus within the left renal lower pole.
Zoomed coronal and sagittal reconstructions highlight the left-sided filling defects and right-sided clubbed calyces.
Case Discussion
Features consistent with renal papillary necrosis of the medullary subtype with a left-sided ball-on-tee appearance. There is calyceal blunting likely following papillary sloughing and epithelialization on the right.
There was clinical and radiological suspicion of pyelonephritis however the work-up for non-tuberculous infection (urine and blood cultures ) and urogenital tuberculosis was negative.
We attributed the renal papillary necrosis due to diabetes in the presence of further negative work-up for other causes.
Image courtesy: Dr Amaresh I. Ranchod
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