A young man with flank pain and dysuria

A 22-year-old man with past medical history of type 1 diabetes, intravenous polysubstance use, bacterial endocarditis, and frequent urinary tract infections presented to the emergency department with left-sided flank pain and dysuria. The pain had been worsening over the last 3–4 days and associated with dysuria, foul smelling urine, and urine “clumps.” He was noted to be ill-appearing with left costovertebral angle tenderness. Vital signs were heart rate of 114 bpm, blood pressure of 122/66, temperature of 37.5°C, respiratory rate of 18 breaths per minute, and pulse oximetry of 97% on room air. Labs were notable for blood glucose 431 mg/dL, beta hydroxybutyrate 2.83 mmol/L, leukocytosis of 13.2 K/µL, creatinine 1.15 mg/dL, and normal lactate. Urinalysis was consistent with infection. Ultrasound showed a hyperechoic area in the renal pelvis with heterogenous appearing posterior acoustic shadowing (Figure 1, Video 1).

M Prats has received payments from Butterfly Network, Inc. for consulting on educational materials. Advertising payments were made to M Prats' businesses Exo Imaging, Inc. and Echonous Inc.