Infected Spontaneous Renal Fornix Rupture Secondary to Obstructing Ureteral Calculus: Role of Urgent DJ Stenting and Culture-Guided Therapy

Abstract

Background: Spontaneous renal fornix rupture (SRF) is an uncommon, potentially life-threatening urological emergency resulting from a precipitous rise in intraluminal pressure due to acute upper urinary tract obstruction. In infected, obstructed systems, the clinical scenario is heavily compounded by the risk of rapid urosepsis, retroperitoneal abscess formation, and permanent parenchymal damage. Urgent, minimally invasive decompression remains the cornerstone of management to protect the renal unit and interrupt the septic cascade. Case Presentation: A 43-year-old female presented to the emergency department with acute-onset left flank pain, high-grade fever, and constitutional symptoms. Laboratory evaluations demonstrated severe leukocytosis (WBC: 17.6 × 10 3 /μL), an elevated C-reactive protein (CRP: 27.9 mg/L), and acute kidney injury with a presumed Stage 1 AKI indicated by a serum creatinine of 1.32 mg/dL against an unknown baseline. Contrast-enhanced computed tomography (CECT) urography with delayed excretory phase imaging demonstrated left-sided obstructive nephropathy secondary to an obstructing proximal ureteral calculus causing moderate hydroureteronephrosis, and active contrast extravasation from the superior calyceal fornix into the perirenal space, confirming the formation of a localized urinoma. Empiric antibiotic therapy was adjusted following urine cultures that grew Escherichia coli resistant to ceftriaxone but sensitive to carbapenems. Due to the high risk of systemic sepsis from an infected, obstructed urinary system, an urgent cystoscopy was performed, and a 6 French, 26 cm Double-J (DJ) stent was retrogradely deployed under spinal anesthesia alongside the administration of intravenous Ertapenem. Following decompression, the patient showed rapid clinical improvement: acute pyrexia and severe flank pain resolved within 24 hours, while overall laboratory values and serum creatinine normalized to 0.8 mg/dL by day 3. The DJ stent was maintained in situ for 6 weeks during which the underlying calculus passed spontaneously. A post-removal retrograde pyelogram (RPG) confirmed complete restoration of pelvicalyceal architectural integrity without residual urine leakage or stricture formation. Conclusion: Spontaneous renal fornix rupture accompanying obstructive pyelonephritis demands swift diagnosis and immediate surgical decompression. Decompression should never be delayed by the false assumption that spontaneous rupture provides adequate systemic drainage. CECT urography with a delayed excretory phase is the diagnostic standard of care, while follow-up retrograde studies are essential to objectively confirm functional healing of the upper tract.