What is the likely diagnosis and recommended management for a 34-year-old woman with cervical cancer on cisplatin‑paclitaxel chemotherapy who has acute pyelonephritis, persistent leukocytosis after four days of ceftriaxone, is afebrile for more than 48 hours, has stable blood pressure, and ultrasound shows moderate hydronephrosis with bilateral double‑J stents?

Likely Diagnosis and Management

Most Likely Diagnosis

This patient most likely has persistent/complicated acute pyelonephritis with obstructive uropathy secondary to cervical cancer progression, rather than treatment failure of the infection itself. The clinical picture—persistent leukocytosis despite 4 days of appropriate antibiotics, bilateral hydronephrosis with stents in place, and recent chemotherapy—strongly suggests that the underlying malignancy is causing ongoing ureteral obstruction and inflammation, not inadequate antimicrobial coverage 1.

Key Diagnostic Considerations

• Afebrile status for >48 hours with stable blood pressure indicates the infection is responding to ceftriaxone, as 95% of patients with uncomplicated pyelonephritis become afebrile within 48 hours of appropriate antibiotic therapy 1.

• Persistent leukocytosis (WBC 20,000) despite clinical improvement suggests an alternative explanation beyond simple treatment failure, such as ongoing obstruction, stent malfunction, or disease progression 1.

• Bilateral hydronephrosis despite bilateral stents indicates either stent malfunction, stent obstruction, or progressive tumor encasement of the ureters—all complications of advanced cervical cancer 2.

• Recent cisplatin-paclitaxel chemotherapy increases risk for neutropenia and infection, but the elevated WBC with "elevated segs" (neutrophilia) argues against chemotherapy-induced neutropenia 2.

Immediate Management Algorithm

Step 1: Continue Current Antibiotics While Investigating

• Continue ceftriaxone as the patient is clinically improving (afebrile >48 hours, hemodynamically stable), which indicates appropriate antimicrobial coverage 1, 3.

• Obtain urine culture with antimicrobial susceptibility testing immediately if not already done, as this is recommended in all suspected pyelonephritis cases 1.

• Check blood cultures to assess for bacteremia, which can occur in complicated pyelonephritis 1.

Step 2: Urgent Imaging to Assess Stent Function and Complications

• Obtain contrast-enhanced CT scan of the abdomen and pelvis urgently to evaluate for:

  • Stent malposition or obstruction 2, 1
  • Renal or perinephric abscess formation 1
  • Progressive tumor burden causing ureteral obstruction 2
  • Emphysematous pyelonephritis (given recent chemotherapy and potential immunocompromise) 1

• CT is indicated in this case because the patient has persistent leukocytosis, bilateral hydronephrosis despite stents, recent chemotherapy (immunocompromise), and cervical cancer (complicated pyelonephritis) 1.

Step 3: Assess Stent Patency and Consider Intervention

• If imaging reveals stent obstruction or malposition, urgent urology consultation for stent exchange or percutaneous nephrostomy (PCN) placement is required 2.

• PCN may have higher technical success rates than retrograde stenting in cases of extrinsic compression, uretero-vesical junction obstruction, or ureteral obstruction >3 cm, which are common in cervical cancer 2.

• If stents are patent but hydronephrosis persists, this suggests progressive tumor encasement requiring oncology re-evaluation 2.

Step 4: Reassess Antibiotic Coverage Based on Culture Results

• Adjust antibiotics based on urine culture and susceptibility results once available 1, 3.

• If fever recurs or clinical deterioration occurs, broaden coverage empirically to include resistant organisms or consider complications like abscess formation 1.

• Total antibiotic duration should be 10-14 days for complicated pyelonephritis, adjusting based on clinical response and culture results 1, 3.

Critical Pitfalls to Avoid

• Do not assume antibiotic failure based solely on persistent leukocytosis when the patient is clinically improving—leukocytosis may reflect ongoing obstruction or inflammation rather than inadequate antimicrobial therapy 1.

• Do not delay imaging in this high-risk patient—cervical cancer with bilateral hydronephrosis, recent chemotherapy, and persistent leukocytosis all constitute indications for urgent imaging even if afebrile 1.

• Do not overlook stent malfunction—bilateral stents do not guarantee adequate drainage, and obstruction can occur from tumor progression, stent encrustation, or malposition 2.

• Do not switch antibiotics empirically without culture data unless there is clinical deterioration—the patient's afebrile status indicates current therapy is addressing the infection 1, 3.

Oncologic Considerations

• Bilateral ureteral obstruction in cervical cancer indicates advanced disease and may impact prognosis and treatment decisions 2.

• Discuss with oncology whether continued chemotherapy is appropriate given the current complications, as cisplatin-paclitaxel is the standard regimen for advanced cervical cancer but may need to be held during acute illness 2.

• Consider whether urinary diversion (PCN vs. stents) should be maintained long-term based on prognosis, treatment goals, and quality of life considerations 2.