No abstract

A 78-year-old woman (who lived in a warden-controlled apartment) was admitted with a 3-month history of malaise and right-sided abdominal pain that worsened signi®cantly 3 days before her admission. She had fever, chills and a mass in her right upper abdomen. She had been wheelchair-bound because of severe rheumatoid arthritis and chronic obstructive airway disease. Examination revealed a pale, frail woman with a temperature of 38.8uC, tachycardia and tachypnoea, and con®rmed the palpable mass in her right hypochondrium. Laboratory investigations showed a haemoglobin level of 62 g/L, a white cell count of 13.3 g/L an ESR of 114 mm/h, a serum creatinine level of 85 mmol/L, C-reactive protein of 203 mg/L and normal liver function tests. The urine contained numerous pus cells (>100/mL, Escherichia coli at >10 5 c.f.u. on culture). A chest X-ray showed a left mid-zone pneumonia. She was treated with cephalosporins and clarithromycin. Ultrasonography showed a large right hydronephrosis with a perinephric collection and a ®stula inferiorly between the lower-pole collecting system and the gall bladder. CT con®rmed the communicating tract between the renal pelvis and gall bladder, with the perinephric collection (Fig. 1). There was no renal cortical tissue left and the entire kidney and gall bladder appeared as a sac of pus. A nephrostomy tube was inserted and the perinephric space drained by a separate pigtail catheter. The percutaneous nephrostomy tube drained pus initially and later bile. A nephrostogram showed a communication of the renal pelvis, gall bladder and biliary tree (Fig. 2). A day later the nephrostomy was unfortunately dislodged but was re-sited. Despite treatment with adequate antibiotics her left-sided pneumonia progressed and she went into respiratory failure; all attempts at