An Unusual Presentation of Pyelonephritis: Is It COVID-19 Related?

Abstract

In severe cases of COVID-19, late complications such as coagulopathy and organ injury are increasingly described. In milder cases of the disease, the exact time frame and causal path of late-onset complications have not yet been determined. Although direct and indirect renal injury by SARS-CoV-2 has been confirmed, hemorrhagic renal infection or coagulative problems in the urinary tract have not yet been described. This case report describes a 35-year-old female without relevant medical history who, five days after having recovered from infection with SARS-CoV-2, had an unusual course of acute pyelonephritis of the right kidney and persistent fever under targeted antibiotic treatment. A hemorrhagic ureteral obstruction and severe swollen renal parenchyma preceded the onset of fever and was related to the developing pyelonephritis. Sudden thrombotic venous occlusion in the right eye appeared during admission. Symmetrical paresthesia in the limbs in combination with severe lower back pain and gastro-intestinal complaints also occurred and remained unexplained despite thorough investigation. We present the unusual combination of culture-confirmed bacterial hemorrhagic pyelonephritis with a blood clot in the proximal right ureter, complicated by retinal vein thrombosis, in a patient who had recovered from SARS-CoV-2-infection five days before presentation. The case is suspect of a COVID-19-related etiology.

Keywords: COVID-19; Coagulopathy; Hemorrhagic infection; Pyelonephritis; SARS-CoV-2; Ureteral obstruction.

Fig. 1

Contrast-enhanced CT scan at presentation, 100 seconds after intravenous contrast. a, b Microcalcifications and severe hydronephrosis of the right kidney. A dense mass of 75 HU, corresponding to the density of a blood clot, can be seen at the transition of the pyelum to the proximal ureter and is indicated by an arrow. A slight layer of fluid around the kidney can be seen and is suggestive of inflammation. There is a delayed arrival of contrast to the right kidney compared with the left side. In a later phase of the scan, retention of contrast in the right pyelum with delayed drainage was observed. c Ground glass abnormalities (arrows) in the peripheral basal lung areas which were deemed to be remnants of COVID-19

Fig. 2

CT scan without contrast, right after the patient had developed fever. (1) Decreased volume of pyelum/hydronephrosis compared to the previous CT scan. (2) Increased area of lower density in the renal parenchyma, suspect for extension of pyelonephritis as tissue becomes increasingly hydrous. (3) Resorption of the blood clot in the proximal ureter. There are no signs of an encapsulated abscess

Fig. 3

Fundoscopy of the right eye, showing bleeding across the whole retina and segmental signs of an unsharp (swollen) optic disc. a Right eye: central retina, macula in the center. b Right eye: nasal retina

Fig. 4

Contrast-enhanced CT scan. a At presentation. b, c At 4 months after discharge. There is an evident decrease in the volume of the right kidney compared to (a). Furthermore, notice the irregular aspect and decreased density of the surface of the interpolar region (b) and lower pole (c) at the site of the previous infection. This indicates scarring of the renal cortex. Multiple small concrements in the right kidney remain