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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 837-839
Emphysematous polycystic infection in a patient on peritoneal dialysis


1 Department of Nephrology, University of Ottawa, Ottawa, Canada
2 Department of Radiology, University of Ottawa, Ottawa, Canada

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Date of Web Publication24-Jun-2014
 

   Abstract 

Emphysematous infection of the cysts in patients with polycystic kidney disease is very rare and seldom reported. We herein report a case of emphysematous polycystic infection in a 61-year-old male patient who was on peritoneal dialysis for end-stage renal disease caused by adult polycystic kidney disease.

How to cite this article:
Nagaraju SP, Gupta A, Mccormick BB, Khandelwal A. Emphysematous polycystic infection in a patient on peritoneal dialysis. Saudi J Kidney Dis Transpl 2014;25:837-9

How to cite this URL:
Nagaraju SP, Gupta A, Mccormick BB, Khandelwal A. Emphysematous polycystic infection in a patient on peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Sep 19];25:837-9. Available from: http://www.sjkdt.org/text.asp?2014/25/4/837/135175

   Introduction Top


Approximately 30-50% of patients with auto-somal-dominant polycystic kidney disease (ADPKD) will have one or more renal infec­tions during their life time. Cystic infection is one of the common complications; however, emphysematous polycystic renal infection (EPRI) is a very rare entity and has been seldom reported. [1],[2] We herewith report an elderly male with ADPKD who presented with EPRI. To the best of our knowledge, this is the fifth case being reported in the literature of emphysematous cystic infection in ADPKD. [2],[3],[4],[5]


   Case Report Top


Case history and laboratory data

A 61-year-old male patient with end-stage on peritoneal dialysis for the last five years, presented with a history of malaise and left flank pain of five days duration. There was no history of hematuria, urinary tract symptoms, fever or history of instrumentation. There was no history of diabetes and the patient had no residual renal function. He had history of hypertension, well controlled on amlodipine 10 mg daily. The patient was on continuous cycling peritoneal dialysis (CCPD) and his dialysis prescription included total volume of 12 L (day + night exchanges). He was on 1.5% dextrose exchanges with cycler at night (7.5 L) with last fill of 2.0 L of 7.5% icodextrin. He was on additional day exchange in the evening with cycler with 2.5 L of 1.5% or 2.5% dextrose.

On clinical examination, he was lethargic and afebrile (36.9°C) and his blood pressure was 110/80 mmHg, heart rate was 112 beats/min and respiratory rate was 20/min. Abdominal examination revealed tenderness in the left lower quadrant with no guarding, rigidity or rebound tenderness. His exit-site was unremar­kable and the peritoneal effluent was clear.

The laboratory investigations were remar­kable for an elevated white blood cell count of 24.3 × 10 [3] /uL with 85% neutrophils and peri­toneal fluid analysis showed clear fluid with no organisms with a cell count of eight cells/uL. Peritoneal fluid culture showed no growth. Blood culture showed a significant growth of Klebsiella pneumoniae [Table 1].
Table 1: Laboratory investigations in the study patient.

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Findings on imaging

A computed tomography (CT) scan of the abdomen was performed and the images are shown in [Figure 1]a and b. Both kidneys were massively enlarged and contained innumerable cysts. Also, innumerable cysts were present throughout the liver parenchyma. There was evidence of extensive mottled gas with air fluid level present throughout the upper pole of the left kidney. Most of the gas was seen within the cysts and no gas was seen in the peri-nephric area. There was no evidence of obs­truction of the lower urinary tract.
Figure 1: Contrast-enhanced computerized tomography scan of the abdomen (axial view) showing emphysematous polycystic infection involving the upper pole of the left kidney.

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Diagnosis and management

The positive blood cultures and CT findings were highly suggestive of a Klebsiella pneu-moniae emphysematous polycystic infection. There was no evidence radiologically for extension of the infection into the collecting system or parenchyma of the kidney. The pa­tient responded promptly to intravenous pipe-racillin-tazobactim. He was continued on CCPD during his stay in the hospital. He required 4.25% solution for exchanges instead of his regular 1.5% for few days, and was switched back to his regular CCPD orders at the time of discharge. He did not require hemodialysis at any time during this episode of infection. He was also seen by the urology service while in hospital but, due to the good response to medi­cal management, he did not require nephrec-tomy or percutanous drainage. After two weeks of intravenous piperacillin-tazobactim, he was given oral amoxicillin-clavulinic acid for four weeks. With antibiotic treatment, there was marked clinical improvement and he recovered completely, and complete resolution of gas in the cysts was confirmed with follow-up ultrasound.


   Discussion Top


Approximately 30-50% of patients with ADPKD will have one or more renal in­fections during their life time. Cystic infection is one of the common complications; however, EPRI is a very rare entity and has been seldom reported. [1],[2] To the best of our knowledge, this is the fifth case being reported in the literature of emphysematous cystic infection in ADPKD. [2],[3],[4],[5] Anatomically, EPRI should be differentiated from emphysematous pyelonephritis (EPN) complicating ADPKD from the absence of gas in the renal parenchyma, the peri-nephric tissue or collecting system. [2] Although they are anatomically different, both have almost simi­lar prognosis and poor outcome.

EPN is commonly seen in diabetics. [6] The lar­gest case series of EPN reports a mortality rate of 40% with antibiotics alone and that 93% of patients required a percutaneous drain, neph-rectomy or both. [7] Similar to EPN, in the pre­vious four reported cases of EPRI in ADPKD, two required urgent nephrectomy, one required surgical drainage and one other patient died in spite of nephrectomy and antibiotics. [2],[3],[4],[5] Con­trary to the previous case reports, our patient responded well to antibiotic treatment of pro­longed duration and did not require any form of surgical intervention in spite of the presence of extensive gas in the cysts as shown on CT scan. Escherichia coli and Clostridium per-fringens have been demonstrated in previous case reports. [2],[3],[4],[5] In our case, Klebsiella pneumo-niae was isolated from blood cultures, in keeping with previous cases of enteric organisms. Our patient was managed conservatively des­pite extensive disease and outcome was good, probably because of early diagnosis and appro­priate antibiotic therapy; also, the patient was not a diabetic.

This is the first case report of EPRI in a patient on peritoneal dialysis. Also, our patient recovered successfully with conservative ma­nagement alone. This case demonstrates that conservative management along with close monitoring can be a successful modality in the treatment of EPRI occurring in patients with ADPKD, even with extensive disease. It is important for clinicians to be aware of the entity of EPRI and to consider performing a CT scan early among patients with ADPKD with suspected upper urinary tract infections; the finding of gas in the cysts mandates closer clinical monitoring and more prolonged anti­biotic therapy than a simple cyst infection.

 
   References Top

1.Rizk D, Chapman AB. Cystic and inherited kidney diseases. Am J Kidney Dis 2003;42:1305-17.  Back to cited text no. 1
    
2.Sooraj YS, Nainan GK, Joseph F, Thara P. Emphysematous polycystic renal infection. Indian J Nephrol 2010;20:205-6.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Van Zijl PS, Chai TC. Gas-forming infection from Clostridium perfringens in a renal cyst of a patient with autosomal dominant polycystic kidney disease. Urology 2004;63:1178-9.  Back to cited text no. 3
    
4.Lanzas Prieto JM, Alonso De La Campa JM, Perez Garcia FJ, Gutierrez Garcia R, Gonzalez Tuero J, Guate Ortiz JL. Pneumopyocystitis in a patient with adult polycystic kidney disease. Arch Esp Urol 2003;56:536-8.  Back to cited text no. 4
    
5.Medagama UA, Aluvihare AP, Jayasinghe MW, Rosairo S, Fernando DJ. A gas forming infection in a person with diabetes mellitus and adult polycystic kidney disease. Diabetes Res Clin Pract 2007;75:372-3.  Back to cited text no. 5
[PUBMED]    
6.Khaira A, Gupta A, Rana DS, Gupta A, Bhalla A, Khullar D. Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis. Int Urol Nephrol 2009;41:959-66.  Back to cited text no. 6
    
7.Huang JJ, Tseng CC. Emphysematous pyelo­nephritis: Clinicoradiological classification, ma­nagement, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 7
    

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Correspondence Address:
Shankar Prasad Nagaraju
Department of Nephrology, Kasturba Hospital, KMC, Manipal University, Manipal, Karnataka - 576 104
Canada
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DOI: 10.4103/1319-2442.135175

PMID: 24969197

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