Complicated Urinary Tract Infection in a Diabetic Woman

A 46-year-old woman with a medical history notable for poorly controlled diabetes mellitus, stroke, morbid obesity, and gastric stapling surgery presented to the hospital with a 6-day history of nausea, vomiting, abdominal pain, and fever. During the 24 h before presentation, she developed chills and confusion. At presentation in the emergency department, the patient was febrile (temperature, ≤38.9°C), with blood pressure of 115/67 mm Hg, pulse of 110 beats/min, respiratory rate of 40 breaths/min, and normal room-air oxygen saturation. At physical examination, the patient was noted to be lethargic; her abdomen had decreased bowel sounds and was exquisitely tender in the left-upper and lower quadrants, with mild guarding and no rebound. The findings of a pelvic examination were unremarkable. Laboratory studies revealed the following values: WBC count, 12.8 cells/mm3, with 46% bands; serum glucose, 662 mg/dL; blood urea nitrogen, 67 mg/dL; and creatinine, 4.8 mg/dL (previous baseline value was in the normal range). Urinalysis revealed 50–100 WBCs per high-power field (HPF), 50–100 RBCs per HPF, a moderate leukocyte esterase level, and no urine crystals or casts. Abdominal x-ray plain films were obtained (figures 1), after which the patient underwent CT of the abdomen (figures 2). Plain x-ray film of the abdomen CT scan of the abdomen What is your diagnosis?