Case Presentation: A 27-year-old Chinese-American woman presented to the ED for sore throat, flank pain, dysuria, and generalized weakness for 1 week. The symptoms began after returning on a domestic flight. She initially denied any medical history or substance use to multiple providers and insisted her symptoms were due to infrequent bathroom use during the flight.Her initial vitals were T 98.8F, HR 129, RR 25, BP 95/58. She was ill-appearing and cachectic (BMI 13.23). Her mucous membranes were dry, and there were removable white plaques on her oral mucosa. She had right upper quadrant abdominal and bilateral costovertebral angle tenderness. Labs were remarkable for WBC 26100/uL with 6% bands, Hgb 10.5 g/dL, Na 120 mmol/L, K 5.0 mmol/L, BUN 58 mg/dL, Cr 3.21 mg/dL, D-dimer 878 ng/mL, alkaline phosphatase 851 IU/L, GGTP 1044 IU/L, direct bilirubin 1.0 mg/dL, and total bilirubin 1.2 mg/dL. An HIV test and nine-panel urine drug screen were negative. Urine culture grew >100,000 CFU/mL E. coli. Blood cultures were negative. Abdominal CT showed bilateral hydroureteronephrosis, diffuse ureteral wall thickening, and innumerable hypoattenuating liver lesions.The patient was admitted for sepsis due to pyelonephritis and hepatic abscesses. She was treated with broad spectrum antibiotics and then narrowed to ceftriaxone based on E. coli sensitivities. Urology was consulted and performed cystoscopy with bilateral ureteral stent insertion, which improved her pain. Given her presentation and imaging, the patient was suspected to have ketamine uropathy. The finding of bilateral hydronephrosis prompted further questioning of the patient, and she admitted to multiple years of intranasal ketamine use, for which she had been in and out of rehab. A presumptive diagnosis of underlying ketamine uropathy with associated hepatic abscesses was made. She was discharged on Hospital Day 5 on oxybutynin and cefuroxime to complete a 4-week antibiotic course, and scheduled for outpatient follow-up.

Discussion: This case of a previously-healthy young woman presenting with bilateral hydronephrosis, pyelonephritis, and hepatic abscesses prompted a wide differential diagnosis. After initially denying substance use, she eventually conceded a history of intranasal ketamine. Ketamine is an NMDA receptor antagonist that has grown increasingly popular as a recreational hallucinogen, especially among Asians and Asian-Americans. Since 2001, ketamine has been one of the most commonly abused substances in Hong Kong, where ketamine uropathy was first reported in 2007. A 2010 San Francisco study found that 18.2% of Asian-Americans in the dance club scene had abused ketamine. Ketamine ulcerative cystitis can be complicated by hydronephrosis and pyelonephritis; up to 9.8% of cases are also associated with cholestatic liver injury. However, few cases have reported hepatic abscesses associated with ketamine use as seen in our patient. It is suspected that years of ketamine abuse led to altered urinary anatomy and retention predisposing to pyelonephritis, which then seeded to the liver and produced a life-threatening picture of sepsis.

Conclusions: Ketamine uropathy should be on the differential for young, previously-healthy patients presenting with urinary retention and hydronephrosis, and may be complicated by pyelonephritis and hepatic abscess. Asking about specific illicit drugs is crucial in completing a thorough social history, especially ketamine in Asian-Americans with unexplained renal failure, cystitis, or hepatic injury.

IMAGE 1: MRI showing numerous hepatic abscesses

IMAGE 2: CT scan showing hydronephrosis