Diagnostic Assessment — Acute Pyelonephritis
Example 1 of 1 · fictitious patient (Veteran CL)
Diagnostic Assessment
Acute Pyelonephritis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CL, date of birth 17 May 1990, Royal Australian Navy, Marine Technician, enlisted 12 January 2009, medically discharged 04 March 2019. Operational service: Middle East Area of Operations (maritime), 02 June 2014 to 23 August 2014 (warlike, returned early after illness).
Occupational History
As a marine technician the veteran maintained and operated propulsion, power generation and auxiliary machinery in the engine rooms of a frigate, standing long watches in temperatures of 40 to 50 degrees Celsius, wearing coveralls and personal protective equipment, and climbing steep ladders between compartments. During action and boarding stations she could not leave her post for many hours.
Engine room personnel at sea in hot climates are at high risk of heat stress and chronic dehydration, which predisposes to kidney stones and urinary tract infection, and female sailors in particular commonly restrict fluids because access to the heads during long watches is limited. Medical care at sea is provided by a single medical officer or medic, with no imaging and limited antibiotics, and evacuation depends on operational tasking.
History
Veteran CL, a marine technician in the Royal Australian Navy, developed acute left pyelonephritis on 19 August 2014 on warlike maritime service in the Middle East, after weeks of dehydration in the engine room, a cystitis treated with an ineffective antibiotic, urinary retention requiring catheterisation after a back injury, and an obstructing left ureteric calculus. The infection worsened to an obstructed, septic kidney with a renal abscess when evacuation from the ship was delayed.
Timeline
- 02 Jun 2014 — The veteran deployed on a frigate to the Middle East Area of Operations. Her pre-deployment medical recorded no history of urinary tract infection or kidney stones, normal urinalysis and normal renal function. She stood six-hour watches in the engine room, where temperatures reached 48 degrees Celsius. "urinalysis normal, no UTI history"
- 28 Jul 2014 — The ship's medical officer reviewed the veteran for heat exhaustion after a twelve-hour period at boarding stations. She reported drinking about one litre of water a day on watch to avoid leaving the engine room, which had no heads. Urine specific gravity was 1.035 and serum creatinine was raised at 105 micromol/L, consistent with dehydration. "heat exhaustion, SG 1.035"
- 12 Aug 2014 — The veteran slipped on an oily ladder between engine room levels and fell about two metres onto her back. The medical officer diagnosed a lumbar soft tissue injury and prescribed oxycodone 10 mg four times a day. "fall from ladder, oxycodone"
- 13 Aug 2014 — She developed painful urinary retention and the medical officer passed an in-out urethral catheter, draining 900 mL. Post-void residual volumes over the next week remained 200 to 250 mL on the ship's bladder scanner while she continued oxycodone. "urinary retention, catheterised 900 mL"
- 14 Aug 2014 — The veteran presented with dysuria, frequency and suprapubic pain. Urine dipstick showed leucocytes and nitrites, and cystitis was diagnosed. She was given trimethoprim 300 mg daily, the only suitable oral antibiotic in the ship's stock. A urine sample was stored for culture at the next port. "cystitis, trimethoprim commenced"
- 19 Aug 2014 — The veteran woke with left loin pain, rigors and vomiting. The medical officer recorded a temperature of 39.4 degrees Celsius, a heart rate of 118, marked left renal angle tenderness and frank pyuria and haematuria. Acute left pyelonephritis was diagnosed and she was given intramuscular ceftriaxone, the only parenteral antibiotic aboard. The ship was on patrol and a helicopter transfer was not available for 48 hours. "L loin pain, fever 39.4"
- 21 Aug 2014 — She was transferred by helicopter to a coalition role 3 hospital, now hypotensive with a lactate of 4.2 mmol/L. CT showed a 6 mm obstructing calculus at the left vesicoureteric junction with hydronephrosis and a 2.5 cm abscess in the left kidney. A left percutaneous nephrostomy was inserted. Blood and urine cultures grew Escherichia coli resistant to trimethoprim. She was returned to Australia on 23 August 2014. "obstructed septic kidney, abscess"
- 30 Sep 2014 — A urologist removed the calculus by ureteroscopy and later removed the nephrostomy. A DMSA scan on 15 January 2015 showed a scar in the upper pole of the left kidney with the left kidney contributing 41 per cent of total function. "ureteroscopy, left renal scar"
Symptoms
At onset the veteran had sudden left loin pain radiating to the groin, high fever with rigors, nausea and vomiting, painful frequent urination and blood in the urine, following a week of burning on passing urine. Over the next 48 hours she became confused, faint and unable to stand.
Since recovery she has had recurrent urinary tract infections, about four a year, intermittent left loin aching, and anxiety about fluid intake and access to toilets. She has been advised to maintain a high fluid intake and has a permanent scar in the left kidney.
Imaging
- 21 Aug 2014 — CT abdomen and pelvis, role 3 hospital: "6 mm calculus at the left vesicoureteric junction with moderate left hydronephrosis and hydroureter. Swollen left kidney with wedge-shaped areas of reduced enhancement and a 2.5 cm intrarenal abscess in the upper pole."
- 30 Sep 2014 — Retrograde pyelogram: "Resolution of hydronephrosis after removal of the calculus. No residual stone."
- 15 Jan 2015 — DMSA renal scan: "Cortical scar in the upper pole of the left kidney. Differential function left 41 per cent, right 59 per cent."
Onset Date
The most likely date of onset of this condition is 19 Aug 2014.
At that date the veteran was on warlike maritime service in the Middle East Area of Operations, serving in the engine room of a frigate on patrol. She woke with left loin pain, rigors and a fever of 39.4 degrees Celsius, and the ship's medical officer diagnosed acute left pyelonephritis.
This date is appropriate because her urinary symptoms on 14 August 2014 were those of cystitis alone, without loin pain or fever, and the features of kidney infection were first recorded on the morning of 19 August 2014. It falls within her warlike service and within uninterrupted full-time service.
For the lower urinary tract infection, catheterisation and antibiotic causes, the 7 days before onset run from 12 Aug 2014 to 19 Aug 2014 and contain the catheterisation of 13 Aug 2014 and the cystitis treated with trimethoprim from 14 Aug 2014. For the dehydration cause, the 4 weeks before onset run from 22 Jul 2014 to 19 Aug 2014, throughout which she stood engine room watches at up to 48 degrees Celsius on about one litre of water a day, with dehydration documented on 28 Jul 2014. The obstructing calculus and the incomplete bladder emptying were present at onset.
For the worsening causes, the documented worsening was on 21 Aug 2014, when CT showed an obstructed, infected kidney with a renal abscess and she had septic shock. The left ureteric obstruction persisted to that date, and the 48 hours from 19 Aug 2014 to 21 Aug 2014 were spent at sea without imaging, drainage or effective intravenous antibiotics.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Acute Pyelonephritis (ICD-10-AM N10), acute left pyelonephritis complicated by obstruction, a renal abscess and sepsis. No Statement of Principles has been determined for acute pyelonephritis.
Acute pyelonephritis is a bacterial infection of the kidney and renal pelvis, most commonly caused by Escherichia coli ascending from the bladder. It presents with fever, rigors, loin pain and tenderness, nausea and vomiting, usually with or after symptoms of cystitis. Recognised risk factors include recent lower urinary tract infection, inadequately treated infection, urinary tract obstruction by calculi, incomplete bladder emptying, urinary catheterisation and dehydration. Obstruction converts a kidney infection into a surgical emergency, with risks of abscess, sepsis and permanent renal scarring unless the kidney is drained promptly.
The condition began on warlike maritime service in the Middle East on 19 August 2014, was diagnosed the same day and worsened to an obstructed septic kidney with abscess by 21 August 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
19 August 2014.
When did the veteran first present to a health / medical provider for this condition?
19 August 2014.
When was the condition confirmed / formally diagnosed?
19 August 2014.
When did the veteran first present to you (or your practice) for this condition?
21 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by the ship's medical officer on 19 August 2014: fever of 39.4 degrees Celsius with rigors, tachycardia, left loin pain and renal angle tenderness, vomiting, and pyuria with nitrites, following cystitis. It was confirmed at the role 3 hospital on 21 August 2014 by CT, which showed a swollen left kidney with wedge-shaped areas of reduced enhancement typical of pyelonephritis, and by blood and urine cultures growing Escherichia coli.
The CT also showed an obstructing 6 mm left vesicoureteric junction calculus with hydronephrosis and a 2.5 cm renal abscess, which established the worsening. A urologist confirmed the diagnosis and its complications, and a DMSA scan on 15 January 2015 confirmed a resulting scar in the left kidney.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for acute pyelonephritis. The claim is therefore decided on the sound medical-scientific evidence of what causes the condition and on whether, on that evidence, the condition is related to the veteran's service, without the limits of a Statement of Principles. The recognised causes below are drawn from the urological and infectious diseases literature and are set out in the style of Statement of Principles factors.
Legislation: the clinical onset of this condition was on 19 August 2014, after 1 July 2004, during warlike maritime service in the Middle East Area of Operations. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The veteran's warlike service at sea, where the dehydration, the fall, the catheterisation, the cystitis, the onset and the worsening all occurred, is relevant service. Each cause must be related to that service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having a lower urinary tract infection within the 7 days before the clinical onset of acute pyelonephritis; — MET
- The ship's medical officer diagnosed cystitis on 14 August 2014, with dysuria, frequency, suprapubic pain and leucocytes and nitrites on dipstick. This was five days before onset, within the 7 days from 12 August 2014 to 19 August 2014. The infection followed catheterisation at sea for urinary retention caused by opioids prescribed for a service injury.
Cause 2: having obstruction of the ureter or renal pelvis of the affected kidney, including by a urinary calculus, at the time of the clinical onset of acute pyelonephritis; — MET
- CT on 21 August 2014 showed a 6 mm calculus obstructing the left vesicoureteric junction with hydronephrosis, and the calculus was removed by ureteroscopy on 30 September 2014. A stone of this kind forms over weeks, and the left loin pain from the outset on 19 August 2014 indicates that the obstruction was present at onset. The stone formed during weeks of documented dehydration in the engine room on deployment.
Cause 3: undergoing urethral catheterisation or other instrumentation of the urinary tract within the 7 days before the clinical onset of acute pyelonephritis; — MET
- On 13 August 2014 the ship's medical officer passed an in-out urethral catheter to relieve acute urinary retention, draining 900 mL. This was six days before onset, within the 7 days from 12 August 2014 to 19 August 2014. Catheterisation introduces bacteria into the bladder, and the retention followed oxycodone prescribed for the injury sustained in a fall from an engine room ladder.
Cause 4: having incomplete emptying of the bladder at the time of the clinical onset of acute pyelonephritis; — MET
- Post-void residual volumes of 200 to 250 mL were recorded on the ship's bladder scanner from 13 August 2014 to the onset on 19 August 2014, while the veteran continued oxycodone 10 mg four times a day for her service back injury. Residual urine allows bacteria to multiply and ascend to the kidney.
Cause 5: being dehydrated, from inadequate fluid intake or excessive fluid loss, for at least the 4 weeks before the clinical onset of acute pyelonephritis; — MET
- Throughout the 4 weeks before onset, from 22 July 2014 to 19 August 2014, the veteran stood engine room watches at up to 48 degrees Celsius and drank about one litre of water a day because the engine room had no heads and she could not leave her post. Dehydration was documented on 28 July 2014, with a urine specific gravity of 1.035 and a raised creatinine. Low urine flow reduces the flushing of bacteria from the urinary tract and promotes stone formation.
Cause 6: being treated for a lower urinary tract infection with an antibiotic to which the causative organism is resistant, within the 7 days before the clinical onset of acute pyelonephritis; — MET
- From 14 August 2014 the veteran took trimethoprim 300 mg daily, the only suitable oral antibiotic in the ship's stock, for her cystitis. Cultures on 21 August 2014 grew Escherichia coli resistant to trimethoprim, so the cystitis was effectively untreated during the 7 days before onset, from 12 August 2014 to 19 August 2014.
Worsening factors
Worsening 1: having obstruction of the ureter or renal pelvis of the affected kidney at the time of the clinical worsening of acute pyelonephritis; — MET
- The 6 mm left vesicoureteric junction calculus remained obstructing on 21 August 2014, when CT showed hydronephrosis and a 2.5 cm renal abscess and the veteran was in septic shock with a lactate of 4.2 mmol/L. An obstructed infected kidney cannot clear infection without drainage, and a nephrostomy was required.
Worsening 2: being dehydrated at the time of the clinical worsening of acute pyelonephritis; — MET
- From 19 August 2014 the veteran was vomiting and febrile at sea with no intravenous fluids available beyond the ship's limited supply, and she was hypotensive and dehydrated on arrival at the role 3 hospital on 21 August 2014, when the worsening was documented.
Worsening 3: inability to obtain appropriate clinical management for acute pyelonephritis. — MET
- On 19 August 2014 the ship had no imaging, no capacity to drain an obstructed kidney and only a single parenteral antibiotic, and a helicopter transfer was not available for 48 hours because of operational tasking. The infection progressed to an obstructed, septic kidney with an abscess by 21 August 2014 and left a permanent renal scar. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The acute pyelonephritis is a sequela of the veteran's accepted lumbar injury, through the oxycodone-induced urinary retention, catheterisation and incomplete bladder emptying, and of the left ureteric calculus that formed during service-related dehydration. The left renal scar and her recurrent urinary tract infections are in turn sequelae of the pyelonephritis.
Unintended Consequence
Met. The urinary retention was an unintended consequence of oxycodone prescribed by the ship's medical officer for her service back injury, and the catheterisation used to relieve it introduced the infection. Treatment of the cystitis with trimethoprim, the only suitable antibiotic carried, was ineffective against the resistant organism. These are unintended consequences of treatment provided by the Commonwealth while she was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. At onset on 19 August 2014 the veteran was at sea on warlike service on a frigate with no imaging, no urological capability and a single parenteral antibiotic, and the ship's operational tasking delayed her helicopter transfer by 48 hours. During that delay the obstructed kidney progressed to an abscess and she developed septic shock, and the infection left a permanent scar in the left kidney. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that delay the imaging and drainage of an obstructed infected kidney amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 02 Jun 2014, Pre-deployment medical, Medical Officer
- 28 Jul 2014, Ship's medical record, heat exhaustion, Ship's Medical Officer
- 12 Aug 2014, Ship's medical record, lumbar injury, Ship's Medical Officer
- 13 Aug 2014, Ship's medical record, urinary retention and catheterisation, Ship's Medical Officer
- 14 Aug 2014, Ship's medical record, cystitis, Ship's Medical Officer
- 19 Aug 2014, Ship's medical record, acute pyelonephritis, Ship's Medical Officer
- 21 Aug 2014, Admission, CT and microbiology reports, Role 3 hospital, Middle East
- 30 Sep 2014, Operation report, ureteroscopy, Urologist
- 15 Jan 2015, DMSA renal scan, Nuclear medicine physician
- Medical-scientific literature on the causes of acute pyelonephritis (no Statement of Principles determined)
