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Emphysematous pyelonephritis

Published online by Cambridge University Press:  18 March 2016

Chen-Min Hung ,
I-Ting Tsai  and
Po-Jen Yang
Chen-Min Hung
Affiliation:
Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
I-Ting Tsai
Affiliation:
Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
Po-Jen Yang*
Affiliation:
Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
*
Correspondence to: Dr. Po-Jen Yang, No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung 82445, Taiwan; Email: flystar.tw@gmail.com.

Abstract

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Canadian Journal of Emergency Medicine , Volume 19 , Issue 1 , January 2017 , pp. 63 - 64
Copyright
Copyright © Canadian Association of Emergency Physicians 2016 

A 42-year-old woman with uncontrolled diabetes mellitus presented to the emergency department with fever, nausea, dysuria, and left flank pain. Physical examination revealed knocking tenderness on the left costovertebral angle. Laboratory results revealed leukocytosis, diabetic ketoacidosis, and pyuria. An abdominal radiograph showed air in the left renal fossa and ureter (Figure 1). Computed tomography (CT) demonstrated left emphysematous pyelonephritis (EPN) with air collections in the left kidney, perinephric space and ureter, and a calculus at the ureterovesical junction (Figures 2 and 3). The patient was treated with resuscitation, glycemic control, antibiotic therapy, and a percutaneous drainage. After stabilization of the general condition, subsequent nephroureterectomy was performed. The cultures of pus and urine yielded Escherichia coli.

Figure 1

Abdominal radiography showing abnormal gas shadows in the left renal fossa (white arrowheads) and ureter (white arrows), and a radiopaque stone (black arrow).

Figure 2

Air collections in the left renal parenchyma, perinephric space, and ureter (arrow).

Figure 3

A distal ureteral calculus at the left ureterovesical junction (arrow).

EPN is a life-threatening, necrotizing infection of the renal parenchyma, characterized by the presence of air within the kidney, collecting system, and perinephric tissue.Reference Ubee, McGlynn and Fordham 1 , Reference Lin, Chen and Lin 2 Diabetes mellitus is the single most common associated factor.Reference Ubee, McGlynn and Fordham 1 Once high levels of tissue glucose, presence of glucose-fermenting organisms (gas-forming coliform bacteria such as E. coli or Klebsiella pneumoniae), and ureteral obstruction coexist, a urinary tract infection may progress to EPN.Reference Ubee, McGlynn and Fordham 1 - Reference Pontin and Barnes 3

Plain abdominal radiography may show abnormal gas in the renal bed or collecting system.Reference Ubee, McGlynn and Fordham 1 CT is the preferred diagnostic modality because of its high sensitivity and ability to assess the extent of gas patterns.Reference Ubee, McGlynn and Fordham 1 , Reference Pontin and Barnes 3 Treatment of EPN comprises fluid resuscitation, correction of electrolytes and glucose abnormalities, and aggressive antibiotics with Gram-negative bacteria coverage. Definitive surgical management includes percutaneous drainage or nephrectomy for overwhelming sepsis with extensive gas and renal destruction.Reference Ubee, McGlynn and Fordham 1 - Reference Pontin and Barnes 3

Keywords: emphysematous pyelonephritis, diabetes mellitus, percutaneous drainage, nephrectomy

Competing interests: None declared.

References

1. Ubee, SS, McGlynn, L, Fordham, M. Emphysematous pyelonephritis. BJU Int 2011;107(9):1474-1478, doi:10.1111/j.1464-410X.2010.09660.x.CrossRefGoogle ScholarPubMed
2. Lin, WC, Chen, YF, Lin, CH, et al. Reappraisal of the management and outcome of emphysematous pyelonephritis. Kaohsiung J Med Sci 2009;25(1):16-24, doi:10.1016/S1607-551X(09)70035-X.CrossRefGoogle ScholarPubMed
3. Pontin, AR, Barnes, RD. Current management of emphysematous pyelonephritis. Nat Rev Urol 2009;6(5):272-279, doi:10.1038/nrurol.2009.51.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1 Abdominal radiography showing abnormal gas shadows in the left renal fossa (white arrowheads) and ureter (white arrows), and a radiopaque stone (black arrow).

Figure 1

Figure 2 Air collections in the left renal parenchyma, perinephric space, and ureter (arrow).

Figure 2

Figure 3 A distal ureteral calculus at the left ureterovesical junction (arrow).