The urinary bladder was not palpable either. Bedside urine dipstick showed protein 4+, blood

2+. Laboratory results were as follows: Hb 9.8mg/dl, MCV 65 fl, WBC 6.7 × 109/l, Platelet 217 × 109/l, Serum chemistry: sodium (Na+) 128mmol/l, potassium (K+) 4.2mmol/l, urea 15mmol/l, creatinine 430µmol/l, albumin 36g/l, total protein 73g/l. STI571 datasheet Urine culture isolated E. coli. Chest X-ray (CXR) showed cardiomegaly with pulmonary oedema and bilateral pleural effusion. Ultrasonography scan (USS): showed bilaterally dilated calyces with bilateral hydroureters. The bladder wall was diffusely thickened. Diagnoses of acute kidney injury (AKI) secondary to schistosomal related obstructive uropathy with urinary tract infection, and congestive cardiac failure (CCF) secondary to

severe hypertension were made. Patient was appropriately treated with frusemide, amlodipine, praziquantel and antibiotics. Indwelling urethral catheter was passed to monitor the urine output and to relieve possible bladder neck obstruction from the schistosomiasis. Urine output in excess of 2mls/kg/hr was recorded in the subsequent 24 hours. Following the above treatment, the kidney function test normalised with serum creatinine falling to 58 µmol/l. On find more discharge, she was already micturiting freely without urethral catheter in-situ. Patient was discharged to be followed up on outpatient basis and to do combined micturiting cystourethrogram (MCUG) and intravenous urogram (IVU). The radiological

evaluations of the urinary tract could not be done for technical and logistic reasons and patient presented 3 months later with generalised bodily swelling and decreased urine output. She was re-admitted. On second re-admission, BP and other cardiovascular findings were normal. Abdominal examination revealed no organomegaly and no palpable bladder. Urine output was, however, low (0.1ml/kg/hr) over the first 12 hours of re-admission. Serum chemistry results were Na+ 121mmol/l, K+ 4.2mmol/l, urea 63mmmol/l, creatinine 732µmol/l, calcium 1.3mmol/l, phosphate 3.6mmol/l Urethral catheter was re-introduced and high dose frusemide infusion (0.5mg/kg/hr) instituted. Her urine output improved only marginally to 0.4ml/kg/hr in the subsequent days whilst serum creatinine fluctuated between 1500 and 500 µmol/l. IVU to assess the patency of the distal ureters could not be done on account of the unresolved abnormal renal function. Cystoscopic examination could also not be done. Six weeks into admission, surgical exploration of the urinary tract was embarked upon after an attempted insertion of nephrostomy tube led to kidney haemorrhage. Intra-operative findings were as follows: The distal ends of both ureters were much thickened with calcification. Both ureteric orifices were severely stenosed and could not be visualised. Bladder was uniformly thickened with sandy patches. Bilateral ureteroneocystostomy was done with placement of stent.

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