Emphysematous pyelonephritis related to specific gas-forming Escherichia coli without diabetes mellitus

Abstract

A 60-year-old-man without a history of diabetes mellitus, or invasive manipulation or obstruction of the urinary tract was admitted for septic shock. Type I emphysematous pyelonephritis was clear in this case: gas within the renal parenchyma extending into the subcapsular region and the perirenal space was present on spiral computerised tomography (CT). Surgical nephrectomy was performed because biochemistry, urography and CT identified a damaged non-functioning left kidney. The outcome was favourable. All urine, blood and nephrectomy specimen cultures were positive for a specific Escherichia coli which produced a high level of gas compared to a reference E. coli strain in the same standard medium, despite the absence of diabetes mellitus. Certain strains of bacteria are able to produce high levels of nitrogen, carbon dioxide and hydrogen and such fermentation in the absence of a high glucose serum level might explain the acute gas-producing bacterial renal infection.

Emphysematous pyelonephritis in a domestic shorthair cat

“…This may explain how emphysematous urinary tract infections develop in the absence of hyperglycemia with subsequent glucosuria. 4,11 In humans, periodontal disease and immunosuppression have also been reported as predisposing factors. 6,12 Traditional surgery including ureteronephrectomy was the recommended therapeutic intervention in human medicine until recently, with the increasing utilization of interventional techniques such as percutaneous catheters.…”

“…A shift occurred in the 1980s with the standard of care being minimally invasive techniques in combination with medical management for EPN and other causes of ureteral obstruction. [4][5][6]8,11 Percutaneous drainage (eg, drainage via catheters or stents placed with computed tomographic guidance) is recommended for patients with localized areas of gas who still possess functioning renal tissue. 6 Complication rates and failure following minimally invasive techniques alone does increase with increasing severity of EPN.…”

“…A shift occurred in the 1980s with the standard of care being minimally invasive techniques in combination with medical management for EPN and other causes of ureteral obstruction. 4–6,8,11 Percutaneous drainage (eg, drainage via catheters or stents placed with computed tomographic guidance) is recommended for patients with localized areas of gas who still possess functioning renal tissue. 6 Complication rates and failure following minimally invasive techniques alone does increase with increasing severity of EPN.Two types of EPN have been identified in humans based on ultrasound, with type I indicating parenchymal destruction and/or fluid accumulation, and type II denoted by the presence of fluid in the renal or perirenal spaces and gas in the collecting system.…”

“…4,8 Conservative management such as intravenous fluids, antibiotics and glycemic control have been successful in patients with early disease or mild involvement (gas only in the pelvicalyceal space, but not the peri- or paranephric space or kidneys themselves). 6,11 A comprehensive review of the current human literature has shown that, overall, mortality rates from medical management alone are 50%; medical management combined with an emergency nephrectomy 25%; and medical management with percutaneous drainage only 13.5%. 8 It is also now the standard of care that medical management in combination with minimally invasive techniques should be attempted first, but, if indicated, nephrectomy should not be delayed.…”

Myocardial air collections as a result of infection with a gas producing strain ofEscherichia coli: Figure 1

“…1 2 However, certain strains of E coli are able to produce large amounts of nitrogen, carbon dioxide, and hydrogen in vitro, 3 4 and have been shown to cause gas accumulation in vivo-for example, in emphysematous pyelonephritis. 5 Serial thoracic CT scans showed that the intramyocardial air collections decreased in size during antibiotic treatment. Unfortunately, the patient died during an episode of ventricular fibrillation.…”