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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 1  |  Page : 97-99
Emphysematous pyelonephritis in a non-diabetic patient with non-obstructed kidney: An unknown entity


Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

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Date of Web Publication22-Jan-2013
 

   Abstract 

Emphysematous pyelonephritis (EPN) is an acute necrotizing infection with evidence of gas inside the kidney, perinephric space, and/or urinary collecting system. This condition is usually encountered in an obstructed urinary system of diabetics or immunocompromised patients and carries poor prognosis. The gold standard for early diagnosis is computed tomography (CT) of the abdomen. Percutaneous/surgical drainage and urgent or delayed nephrectomy are the available treatment options. We report one case of EPN, which was diagnosed in an immunocompetent non-diabetic man with a non-obstructed urinary system.

How to cite this article:
Dubey IB, Agrawal V, Jain BK, Prasad D. Emphysematous pyelonephritis in a non-diabetic patient with non-obstructed kidney: An unknown entity. Saudi J Kidney Dis Transpl 2013;24:97-9

How to cite this URL:
Dubey IB, Agrawal V, Jain BK, Prasad D. Emphysematous pyelonephritis in a non-diabetic patient with non-obstructed kidney: An unknown entity. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jun 2];24:97-9. Available from: http://www.sjkdt.org/text.asp?2013/24/1/97/106300

   Introduction Top


Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by gas within the renal parenchyma or perinephric tissue. [1] This condition is usually seen in diabetic females and immunocompromised patients. [2] Urinary tract obstruction due to calculi is another predisposing factor. Urine culture is generally positive. Although cases with polymicrobial and anaerobic infections have been reported, yet, the most common organism isolated from these patients' is  Escherichia More Details coli (E. coli). [3] Presentation is variable, extending from features of severe acute pyelonephritis to pneumaturia if gas extends into the collecting system. Clinically, patients may be in renal failure due to systemic disease (diabetic nephropathy) or local disease (obstructing calculi). Diagnosis of EPN is difficult on the basis of the history, physical examination and laboratory results, and is usually established following radiological investigations. [4] Plain X-ray abdomen often shows mottled gas shadows over the affected kidney. [5] Ultrasonogram (USG) demonstrates obstruction well, but is less sensitive than computed tomography (CT) at picking up renal gas. The gold standard for diagnosis is the CT scan of the abdomen, as it will show the presence of gas along with the extent of renal parenchymal destruction. [6]

We describe in this report a case of EPN, which was diagnosed in an immunocompetent non-diabetic man with a non-obstructed urinary system.


   Case Report Top


A 55-year old non-diabetic man presented in surgery emergency with history of fever, right flank pain and decreased urine output of ten days duration. His past medical history was unremarkable, except for lower urinary tract symptoms for the last two years. There was no recent history of trauma, urinary catheter insertion or other per urethral instrumentation. The patient did not receive any medication.

On physical examination, his temperature was 101.9°F, pulse 120/min, and systolic blood pressure 70 mmHg. Cardiac, respiratory, and neurological examinations were unremarkable. Signs of dehydration and facial puffiness were present. Right renal angle was tender with guarding on the right lumbar region. There were no clinical organomegalies and prostatic evaluation was also unremarkable.

Laboratory evaluation revealed white cell count 22,000 cells/mm 3 , hemoglobin 8.4 gm/dL, sodium 163 mmol/L, potassium 6.8 mmol/L, glucose 89 mg/dL and serum creatinine 9.3 mg/dL. Urinalysis revealed cloudy urine with pH 5.0 and numerous white blood cells on microscopy. Urine cultures grew E. coli. Urinary tests for fungal infection and Mycobacterium tuberculosis were negative.

Ultrasonographic examination revealed enlarged hydronephrotic right kidney with heterogenous echotexture and hyperechoic shadows in the renal parenchyma suggestive of air. Ipsilateral ureter and opposite kidney were unremarkable. CT of the abdomen revealed gas in the right kidney extending into the pararenal area, and, thus, confirmed the diagnosis of EPN [Figure 1] without any evidence of calculi in the renal tract. There was a mild dilatation of the right ureter without any obstruction.
Figure 1: CT scan shows gas in the right kidney.

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Fluid resuscitation, inotropic support, and broad-spectrum antibiotics (aminoglycoside plus third generation cephalosporin) were administered.

Right simple nephrectomy was performed after stabilization of the patient's condition using an extraperitoneal flank approach. In the post-operative period, the patient developed coagulation abnormality, which was managed with transfusion of coagulation factors. Peritoneal dialysis was started in the immediate post-operative period for improving the renal function and to salvage the patient as hemodialysis was not possible due to persistent hypotension refractory to inotropes. The patient died on the second post-operative day due to ongoing septicemia and renal failure. Histopathological examination confirmed the diagnosis of EPN. E. coli was isolated from culture of perinephric fluid, while tissue culture was positive for Klebsiella.


   Discussion Top


Four classes of EPN have been proposed by Huang et al on the basis of CT scan of the abdomen. [1] Class 1: gas is present in the collecting system only (emphysematous pyelitis); class 2: gas is present in the renal parenchyma without extension to the extrarenal area; class 3A: gas and or abscess are present in the perinephric space; class 3B: gas or abscess present in the pararenal area; class 4: bilateral EPN of any class is present or EPN in solitary kidney. The risk of mortality increases with each class, with class 4 being the worst.

Wan et al proposed another radiological classification with two types: [7] type 1: parenchymal destruction with gas, but no collection, and type 2: perinephric collection and gas in the collecting system. The prognosis is much worse in type 1, with mortality of 70% versus 20% in type 2.

Treatment of EPN is controversial. Citing high mortality with medical therapy, several authors have advocated aggressive early surgical intervention consisting of total nephrectomy. [6] Case reports of medical management alone, medical management combined with percutaneous drainage, or emergency nephrectomy have been published. [2] Mortality ranges between 20% to more than 80%. [8]

Our patient was a loner, elderly malnourished man with poor general hygiene and lower urinary tract symptoms. He was diagnosed as a case of EPN (class 3B and type 1) on abdomen CT scan. There was no evidence of diabetes mellitus or immunocompromise. He was having hydronephrotic kidney on the affected side without any demonstrable obstruction in the urinary system, and it could have been caused by mucosal edema of the pelvicalyceal system subsequent to the infection, resulting in stasis and backpressure effects due to intermittent obstruction caused by sloughed papilla, debris, and pus. It seems likely that urinary tract infection with rightsided vesicoureteric reflux resulted in ascending infection of the kidney and subsequent EPN. We managed our patient medically with ongoing resuscitation during the first 48 h. Nephrectomy was planned after stabilization of the vital signs. Dialysis support was continued in the post-operative period. However, the patient died in the early post-operative period even after undergoing nephrectomy, which is considered to be the standard treatment of emphysematous pyelonephritis.

We conclude that EPN is a serious disease associated with a high mortality than conventional cases of pyelonephritis. Majority of the sufferers are diabetic females. In rare instances, even males with no predisposing factors may be harboring this disease. A high index of suspicion is needed for early diagnosis, and is confirmed by CT scan of the abdomen. The treatment approach should be individualized. Sometimes, the approach needs to be aggressive; if failure of medical therapy is anticipated, in these circumstances, nephrectomy should not be withheld as timely intervention is a key to successful outcome.

 
   References Top

1.Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiologic Classification, Management, Prognosis, and Pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 1
[PUBMED]    
2.Abdul-Halim H, Kehinde EO, Abdeen S, Lashin I, Al-Hunayan AA, Al-Awadi KA. Severe emphysematous pyelonephritis in diabetic patients: Diagnosis and aspects of surgical management. Urol Int 2005;75:123-8.  Back to cited text no. 2
[PUBMED]    
3.Weinrob AC, Sexton DJ. Urinary tract infections in patients with diabetes mellitus. In: Rose BD, ed. UpToDate. Waltham, Mass: UpToDate; 2007.  Back to cited text no. 3
    
4.Sujitranooch B. Emphysematous pyelonephritis: A case report and review of literatures. J Med Assoc Thai 2008;91:240-3.  Back to cited text no. 4
[PUBMED]    
5.Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int 2007;71:562-5.  Back to cited text no. 5
[PUBMED]    
6.Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. Br J Urol 1995;75:71-4.  Back to cited text no. 6
[PUBMED]    
7.Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas producing bacterial renal infection: Correlation between imaging findings and clinical outcome. Radiology 1996;198:433-8.  Back to cited text no. 7
[PUBMED]    
8.Flores G, Nellen H, Magaña F, Calleja J. Acute bilateral emphysematous pyelonephritis successfully managed by medical therapy alone: A case report and review of literature. BMC Nephrol 2002;3:4.  Back to cited text no. 8
    

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Correspondence Address:
Indu Bhushan Dubey
Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
India
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DOI: 10.4103/1319-2442.106300

PMID: 23354201

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