Case presentation
The patient was a 49-year-old Japanese female who was living in the United States. She complained of fever and abdominal pain. Her medical history was not contributory. Total pelvic exenteration for cervical carcinoma, Miami pouch formation, and ileostomy were performed in the USA (SCCpT3bN1aM1). She returned to Japan to undergo postoperative adjuvant chemotherapy. Fever and abdominal pain occurred 42 days after surgery, and she consulted the fever outpatient clinic of our hospital. Abdominal computed tomography (CT) revealed enlargement of the Miami pouch, bilateral mild hydronephrosis, and right renal atrophy. Furthermore, bilateral ureteral stents had been placed (Figure 1). Blood biochemistry showed severe nephropathy and severe infection (Table 1). A diagnosis of urinary-retention-associated acute renal failure and pyelonephritis was made based on topical findings and pyuria/bacteriuria.
The patient was urgently admitted. On admission, consciousness was clear and blood pressure, pulse, and body temperature were 129/76 mmHg, 112 bpm, and 40.0℃, respectively. Her abdomen was flat, and there was a surgical wound in the midline. In the right lower abdomen, a urinary stoma was present, and a stent had been placed; moreover, pressure pain was noted at the site. Ileostomy on the left abdomen had been performed.
We attempted to insert a catheter into the pouch, but insertion was difficult. This may have led to incomplete self-catheterization, resulting in urinary retention. There was no stenosis; therefore, we inserted an endoscope. Intra-pouch urine was markedly turbid, and two stents were observed. The margin of one stent was placed in the pouch. The two stents were left, and a catheter was inserted into the pouch. To treat pyelonephritis, twice-a-day ceftriaxone administration at 2 g/session was started. Despite an improvement in drainage from the pouch, there was no marked improvement in hematological data (Table 1). We detected Enterococcus faecium (VRE) on urine/blood culture 5 days after admission. Once-a-day daptomycin was administered (600 mg, 12 mg/kg) at 48-hour intervals. On Day 8, bilateral ureteral stents were exchanged, leading to the resolution of hydronephrosis. The blood flow data gradually improved (Table 1), and the pain was resolved on Day 9. On Day 11, erythematous eruption appeared on the trunk and the upper limbs. Considering the possibility of an adverse reaction to daptomycin, administration was discontinued, and linezolid (300 mg) was administered twice a day. A blood culture test on the same day was negative. On Day 18, pyretolysis was achieved (Figure 2). The patient was discharged on Day 35.
Ureteral stents were removed, and an intra-pouch catheter alone was placed. In the bilateral kidneys, grade 2 hydronephrosis was noted, but, subsequently, there was no urinary tract infection-related fever. Cervical carcinoma gradually progressed, and the patient died 24 months after surgery.