A 16-year-old white female presented to the emergency department (ED) with complaints of multiple episodes of vomiting, colicky left flank, and lower quadrant abdominal pain for 2 days. She denied fevers, dysuria and, gross hematuria but complained of urinary frequency. A review of systems was unremarkable. Past medical history was significant for poorly controlled insulindependent diabetes mellitus and autosomal dominant polycystic kidney disease. Her last menstrual period was 2 weeks prior, and her other gynecological history was unremarkable. Vital signs, including blood pressure (BP) were normal. Physical examination was remarkable for non-specific mild left lower quadrant tenderness, and there was no costovertebral angle, rebound tenderness, or masses on palpation. Results of laboratory data are shown in Table 1. A 1-L bolus of normal saline was administered intravenously, followed by morphine and acetaminophen/ oxycodone. Within a few hours she was completely pain free and discharged home with instructions to follow up with her nephrologist within 1 week. She returned to the ED 2 days later due to worsening of colicky abdominal pain, vomiting, and tactile fever. On physical examination she was alert but ill appearing, mildly dehydrated, and afebrile, and she had a BP of 133/88 mmHg. The abdomen was distended but soft, with left flank pain and left costovertebral angle tenderness, no masses were palpable, and rebound tenderness was absent. Repeat laboratory data results are shown in Table 1. Urine culture obtained at initial presentation was positive for >100,000 colony forming units of Escherichia coli that was sensitive to a host of antimicrobial agents. A pregnancy test was negative. An assessment of pyelonephritis was made, but due to the persistence of colicky abdominal pain, a non-contrast computerized tomography scan was performed (Fig. 1). The answer to this question can be found at http://dx.doi.org/10.1007/ s00467-010-1561-7. A. Omoloja : L. Canessa Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
Read full abstract
May 1, 2011
Joanne Kaldy 
Open Access