Emphysematous pyelonephritis: a case report

Abstract

Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding areas, characterized by the presence of gas within the kidney and perinephric tissue. 1 It occurs almost exclusively in patients with diabetes mellitus.2,3 The disease predominantly affects women. Escherichia coli is the causative bacterial source in approximately 70% of the cases, with Klebsiella, Candida and Pseudomonas species less frequently isolated.4,5 Gas formation in EPN is due to pathogenic bacteria causing mixed acid fermentation in a hyperglycemic environment in tissues that are ischemic. The clinical manifestations are those of pyelonephritis such as dysuria, fever, nausea, vomiting, flank pain. Other potential clinical manifestations include acute renal dysfunction, hyperglycemia, thrombocytopenia, lethargy, acid-base irregularities. EPN is a life-threatening disease associated with septic complications. EPN requires a radiological diagnosis. Computed tomography (CT) is the imaging test of choice to confirm the presence and extent of the parenchymal gas. Case ReportA 68-year-old woman was admitted to the medical ward with a one-day history of left lower abdominal pain, vomiting and fever. She had a history of hypertension and type 2 diabetes mellitus, treated with oral anti-diabetic drugs. On examination she presented with fever (39.1°C), her blood pressure was 160/80 mm/Hg and the heart rate was 87 beats per minute. She had left flank pain, accentuated by local palpation. Cardiorespiratory examination was normal. She presented without any focal neurological deficit.Her blood tests showed renal impairment, decompensated diabetes, a high leukocyte count with a neutrophil segment, high inflammatory markers and a very high pro-calcitonin (Table 1). Urinalysis showed the presence of hyaline cylinders. Urine and blood samples were collected for bacterial culture analysis. A plain abdominal radiograph revealed no pathological findings; a renal ultrasound was performed revealing dilatation of the pelvicalyceal system and upper ureter of the left kidney (0.6 cm diameter). The patient was managed with intravenous fluids and insulin to achieve euglycemia. In suspicion of pyelonephritis, empiric intravenous antibiotics in the form of levofloxacin and meropenem were administered. A plain non-contrast CT (NCCT) scan demonstrated the presEmphysematous pyelonephritis: a case report ABSTRACTEmphysematous pyelonephritis is a severe, life-threatening, necrotizing kidney disease. It occurs almost exclusively in patients with diabetes mellitus. The clinical manifestations are those of pyelonephritis such as dysuria, fever, nausea, vomiting and abdominal pain. The diagnosis is radiological. The treatment strategies are controversial. They include medical management only, percutaneous catheter drainage plus medical management, emergency nephrectomy plus medical treatment or percutaneous drainage plus medical management and emergency nephrectomy. We present the case of a 68-year-old woman affected by e...

Reply to: Emphysematous pyelonephritis: a case report

“…To the Editor: I read the article of Tiraterra et al (doi: 10.4081/ itjm.2015.553) about emphysematous pyelonephritis affecting a 68-year-old woman with hypertension and type 2 diabetes mellitus. 1 She had anemia, neutrophilic leukocytosis and elevated levels of inflammatory markers; the urine culture showed Escherichia coli, and imaging studies revealed gas in the left kidney parenchyma. Worthy of note, the radiological condition of the patient was class 2 by Huang and Tseng classification, which often requires clinical management plus percutaneous catheter drainage.…”

“…Worthy of note, the radiological condition of the patient was class 2 by Huang and Tseng classification, which often requires clinical management plus percutaneous catheter drainage. 1 In spite of uncontrolled diabetes, hydronephrosis, proteinuria and renal function impairment, the result of her early medical treatment and use of effective antimicrobials was successful. The patient was discharged, in good clinical conditions, after three weeks of hospitalization.…”

“…The patient was discharged, in good clinical conditions, after three weeks of hospitalization. 1 The authors emphasized the role of rapid diagnosis and prompt adequate antibiotic therapy, which have changed traditional options for management of emphysematous pyelonephritis. 1,2 Actually, the case study herein commented is an important contribution in this setting; however, I would like to highlight the result of the Italian study with a similar Brazilian case.…”

“…1 The authors emphasized the role of rapid diagnosis and prompt adequate antibiotic therapy, which have changed traditional options for management of emphysematous pyelonephritis. 1,2 Actually, the case study herein commented is an important contribution in this setting; however, I would like to highlight the result of the Italian study with a similar Brazilian case. 2 A 70-year-old woman with hypertension and type 2 diabetes mellitus had the diagnoses of bilateral nephrolithiasis, cystitis, pielitis and pyelonephritis emphysematous by E. coli.…”

“…2 In both patients, the agent was E. coli, which has been detected in up to 75% of these cases. 2 The Italian as well as the Brazilian authors prescribed levofloxacin and meropenem, 1 and ciprofloxacin, 2 empirical options that were concordant with respective susceptibility tests. 2 Early diagnosis and immediate antibiotic therapy may control this potentially severe condition without using invasive procedure; 1,2 but the routine management of emphysematous pyelonephritis would merit well-controlled evaluations.…”