Emphysematous Pyelonephritis Presenting as Pneumaturia and the Use of Point-of-Care Ultrasound in the Emergency Department

Abstract

Emphysematous pyelonephritis (EPN) is a rare form of pyelonephritis causing a severe infection of the renal system that includes gas in the renal parenchyma, collecting system and surrounding tissue often presenting with sepsis. We report the case of a 60-year-old male with poorly controlled insulin dependent diabetes mellitus who presented with abdominal pain, nausea, vomiting, and “peeing air.” CT scan revealed air extending from the left renal parenchyma, perinephric fat and into the bladder, consistent with emphysematous pyelonephritis. Bedside point-of-care ultrasound (POCUS) subsequently revealed dirty shadowing and reverberation artifacts in the left kidney and the bladder consistent with gas in the urinary collecting system. By understanding the identifying artifacts seen with EPN, reflective shadow and reverberation artifact, the emergency physician may be alerted to the diagnosis sooner. Often this illness presents similarly to simple, acute pyelonephritis or undifferentiated sepsis. Therefore, POCUS allows for real time consideration of this condition while in the emergency department and thus prompter time to treatment.

Pneumoparotid: Practical impact of Surgeon performed Ultrasound in an effective Diagnostic Approach

“…The ultrasound appearance of air has been extensively studied in the peritoneal and thoracic cavities (Brown et al, 2019; Buttar et al, 2017; Shokoohi et al, 2016). For pneumoparotid, not more than 50 patients with this condition have been described in the literature during the last 30 years (Gazia et al, 2020), but an extensive analysis of pneumoparotid has not yet been conducted (Ghanem et al, 2012; Goncalves et al, 2020; Goncalves, Mantsopoulos, Schapher, Zenk, et al, 2019).…”

Renal Vein Thrombosis on Point-of-care Ultrasound in the Emergency Department: A Case Report

“…While the presence or absence of hydronephrosis is the primary clinical question the emergency physician must answer, clinicians using POCUS have become more adept at identifying additional renal pathologies. There are multiple case reports of other diseases identified on renal POCUS including renal trauma, 5 renal cell carcinoma, 6 urinomas, 7 emphysematous pyelonephritis, 8 pyonephrosis, 9 and xanthrogranulomatous pyelonephritis. 10 Furthermore, its routine use in some other conditions has been advocated.…”

Point-of-care ultrasound for the early diagnosis of emphysematous pyelonephritis: A case report and literature review

“…The high acoustic impedance gradient between gas and renal tissues generates artifacts, which can be easily detected on POCUS at the bedside[ 42 , 43 ]. We performed a systematic literature search in PubMed using the key words “POCUS,” “point-of-care ultrasound,” “bedside ultrasound,” “emergency ultrasound,” “ultrasound,” and “emphysematous pyelonephritis.” A total of five other reports focusing on POCUS in EPN were identified[ 3 , 19 , 44 - 46 ] (Table 2 ). A hyperechoic focus with dirty acoustic shadowing is the most common sonographic feature on POCUS for the diagnosis of EPN[ 3 , 19 , 45 ].…”

“…A hyperechoic focus with dirty acoustic shadowing is the most common sonographic feature on POCUS for the diagnosis of EPN[ 3 , 19 , 45 ]. However, other imaging features have also been reported, including poor delineation of the kidney, A-lines and B-lines[ 44 - 46 ]. Additionally, we report that the comet-tail artifacts and the “falls” sign are also imaging features on POCUS in EPN.…”