LAUSR

A 14-year-old African American male presented with 4 days of right flank pain. He described the pain as constant, sharp, crampy, and nonradiating. It improved with hot showers and was worse with palpation and urination. In addition, he reported fatigue, urinary incontinence, a 30-pound weight loss, and high blood pressure for the last year. He reported dribbling when he had the urge to urinate and denied a full urinary stream with voiding. He had to wear pull ups to school for the last year due to incontinence. He had tried to restrict fluid intake, but this did not alleviate his symptoms. He denied fevers, dysuria, any prior urinary tract infections (UTIs), stool incontinence, and history of any sexual activity. Upon arrival to the emergency department (ED), he was hypertensive with a blood pressure of 156/98. He was afebrile, and other vital signs were normal. On examination, he had right costovertebral angle, right lower quadrant, and suprapubic tenderness. He had urine dribbling from his urethral meatus. In addition, bilateral inguinal lymphadenopathy and shotty cervical lymphadenopathy were present. Urinalysis showed elevated protein (100 mg/dL), 1+ blood, 3+ leukocyte esterase, and urine bacteria high power field (309/HPF). His creatinine was elevated to 2.08 mg/dL, and blood urea nitrogen (BUN) was elevated to 46 mg/dL. He had a mildly increased magnesium (2.4 mg/dL) and a high normal phosphorus (5.2 mg/dL). Complete blood count results were significant for a low hemoglobin of 9.7g/dL, and elevated white blood cell (WBC) and absolute neutrophil count (ANC) to 18.30/uL and 15.56/uL, respectively. Renal ultrasound (Figure 1) showed bilateral high-grade hydronephrosis (SFU grade 4) and hydroureter with urothelial thickening plus bladder wall thickening and intracystic debris. This constellation of findings was concerning for bilateral pyelonephritis, prompting initiation of ceftriaxone. Hospital Course