| Abstract|| |
We report a 53 years old Saudi man a known diabetic for more than 15 years. He presented with lower abdominal pain, diarrhea and vomiting. He had symptoms and signs of sepsis. He had pancytopenia, renal failure, and his blood culture grew E.Coli. He remained febrile despite antibiotics administration for one week and developed crepitation over both thighs. Radiologically, plain-x ray, ultrasound and CT scan of the abdomen confirmed the presence of air in the left kidney involving the renal parenchyma and the collecting system and extensive gas in subcutaneous tissue of the thighs with abscesses. Repeated surgical drainage of the renal and the extra renal abscesses helped the antibiotic that was continued for several weeks to control the infection. Emphysematous pyelonephritis is a rare but life threatening condition that can be difficult to treat especially if the gas forming organism extends outside the kidney.
Keywords: Emphysematous, Pyelonephritis, Thigh abscess.
|How to cite this article:|
Hamza A E, Abutaleb N, Obeidin A G, Al-Subaity YH, Al-Kamel A A, Sarwar M S. Emphysematous Pyelonephritis Complicated with Extrarenal Abscesses. Saudi J Kidney Dis Transpl 2004;15:61-5
|How to cite this URL:|
Hamza A E, Abutaleb N, Obeidin A G, Al-Subaity YH, Al-Kamel A A, Sarwar M S. Emphysematous Pyelonephritis Complicated with Extrarenal Abscesses. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2019 Sep 20];15:61-5. Available from: http://www.sjkdt.org/text.asp?2004/15/1/61/32968
| Introduction|| |
Urinary tract infection is a significant problem in diabetic patients because of the multiple effects of this disease on the urinary tract and host immune system. Complicated urinary tract infections associated with diabetes include renal and perirenal abscesses. Gas forming infection is a rare entity that manifests as emphysematous pyelonephritis, emphysematous pyelitis or emphysematous cystitis. ,,,,,, fungal infection, xanthogranulomatous pyelonephritis and renal papillary necrosis are other rare entities that may be encountered in practice. Emphysematous pyelonephritis, though first described 100 years ago,  is an important entity to consider in diabetic patients, since 80% of the reported cases occurred in them.
| Case Report|| |
A 53-year-old man with 15-year-history of insulin dependent diabetes presented to our hospital for the first time with a complaint of left lower abdominal pain, loose motions and vomiting for 3 days.
The patient was alert and oriented but looked acutely ill and septic with blood pressure of 123/65, pulse 130 and temperature of 38.2. His cardiovascular and chest examination were unremarkable, while his abdominal examination revealed diffuse tenderness, without organomegalies.
The urine exam showed glucose ++, blood ++ with protein and nitrate +. The complete blood count showed hemoglobin 114 grams /l, white blood cells (WBC) 1700 cells/ microliter and platelets 49,000/microliter. The serum creatinine was 240 µmol/l, urea 19mmol/l, Na 130mmol/l, K3.7mmol/l, glucose 31mmol/l, albumin 29grams/l.
We obtained blood, urine and stool specimens for culture and sensitivity and started the patient on IV Ciprofloxacin with IV fluid. After 48 hours his blood culture grew E.Coli sensitive to gentamicin and aztreonam. We started the patient on gentamicin IV with adjusted dose according to the assay of level.
On day three of hospitalization, ultrasound (US) abdomen was performed, which showed multiple hyperechoic lesions (air) observed in the left kidney without hydronephrosis, [Figure - 1].
The computerized tomography (CT) of the abdomen performed without contrast on the same day showed extensive gas in the left renal parenchyma and collecting system and in the subcutaneous tissue of the buttocks and gluteus muscle, [Figure - 2] A and B.
Diagnosis of emphysematous pyelonephritis was made and the patient was continued on gentamicin for one week. The general condition of the patient improved but he remained febrile with impaired renal function, so we switched gentamicin to aztreonam.
We repeated the US of the abdomen on day eight to rule out any obstructive lesions and pelvicaliceal dilation was noted, [Figure - 3]. We attempted to relieve the obstruction by inserting a stent (DJ stent), but the patient remained febrile.
On day 17 of hospitalization, we found bila-teral crepitations on both thighs of the patient; more on the right side. The plain radiography of the thighs showed air in both thighs within the vastus laterals muscle, [Figure - 4]. The findings were confirmed by CT of both thighs.
On day 18, the orthopedic surgeon incised and drained 40ml of pus from the abscesses of both thighs; the culture was negative. The patient remained febrile despite the antibiotic coverage with aztreonam. It was switched after 15 days to meropenum for another seven days. Another left thigh abscess was detected by follow-up CT and it was incised and drained on day 24; a drain was kept in situ this time. The patient improved but continued to have low-grade fever around 37.6, 37.8. Right thigh abscess was found later and was treated surgically again.
On day 50 of hospitalization, the patient was off the antibiotics and afebrile. He was discharged home with serum creatinine of 126µmol. Repeated CT of the thigh was normal after 135 days of the incident.
| Discussion|| |
Emphysematous pyelonephritis is a severe necrotizing form of acute multifocal bacterial nephritis that results in the presence of gas with in the renal parenchyma. E .Coli is the cause in 60% of the cases. Other gram-negative bacilli such as: Enterobacter, Klebsiella, Streptococci and Candida have also been reported.
Three factors are necessary for the renal emphysema to occur that include the presence of gas forming bacteria, high local tissue glucose level and impaired tissue perfusion. The source of gas formation remains obscure, but several explanations are feasible. The Enterobacteriaceae can produce gas in vitro by mixed acid fermentation.CO2 is formed from fermentation of glucose and tissue of the infecting bacteria. Another proposed mechanism is fermentation of products from necrotic tissue. The common clinical predisposing factors include diabetes mellitus, kidney infection and obstruction. The emphysematous pyelonephritis is more common in women than men. The presenting symptoms are similar to patients with acute pyelonephritis or renal abscess on examination; 50% have flank mass. The dramatic finding of crepitation over the thigh or flank in a diabetic patient is infrequent but when present should raise a high degree of suspicion for emphysematous pyelonephritis with extension into the perinephric space and retroperitonium.
The typical laboratory findings include Hyperglycemia, high WBC, high Urea and creatinine with pyorrhea. The plain abdominal radiograph as renal ultrasound can detect renal emphysema in 85% of cases. If gas is present, CT should be performed to better localize the gas in the renal parenchyma (emphysematous pyelonephritis) or the collection system (emphysematous pyelitis). A recent modification of the radiological classification by Huang et al included class1: gas confined to the collecting system, class2: gas confined to the renal parenchyma, class3a: perinephric extension of gas or abscess, class 3b: extension of gas beyond the Gerota fascia and class4: bilateral or emphysematous pyelonephritis in a solitary kidney. 
In emphysematous pyelonephritis, Candida carries a poor prognosis with medical treatment alone; mortality is 60%-80% in patients treated with antibiotic without surgical drainage. Surgical removal of the involved kidney (nephrectomy) lowers the mortality substantially to 21%-29% or less.  on the other hand, the overall mortality in emphysematous pyelitis is 20% and antibiotic is sufficient therapy if there is no urinary tract obstruction.
The risk factors for developing the emphysematous pyelonephritis in our patient were male gender, urinary obstruction and diabetes. The presentation was not clear for early diagnosis. There were no flank mass or localized tenderness. The first clue came from the US of the abdomen, which detected air in the left kidney that followed by plain abdomen, which showed no air in the kidney but air over both hip bones. The CT scan of the abdomen confirmed the finding and on the same day the blood grew E .Coli (gas producing organism) that makes the diagnosis is almost certain.
The stay of the patient in the hospital was hampered by recurrent extrarenal abscesses in the thighs that were controlled by a long course of frequent surgical drainage and prolonged administration of antibiotic for more than 4 weeks besides the relief of the urinary obstruction by the double J stent.
We conclude that emphysematous pyelonephritis can be missed or delayed in diagnosis and its peculiar extrarenal extension like abscesses in thighs should be considered in the differential in a susceptible patient to decrease morbidity and mortality.
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A E Hamza
Prince Sultan Kidney Center, P.O. Box 100, North West Armed Forces Hospital, Tabuk
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]