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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 1086-1087
Emphysematous pyelonephritis with air in the renal vein and septic emboli in the lungs: A rare presentation


1 Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication2-Sep-2014
 

How to cite this article:
Yadav MK, Bhatia A, Bhalla A, Khandelwal N. Emphysematous pyelonephritis with air in the renal vein and septic emboli in the lungs: A rare presentation. Saudi J Kidney Dis Transpl 2014;25:1086-7

How to cite this URL:
Yadav MK, Bhatia A, Bhalla A, Khandelwal N. Emphysematous pyelonephritis with air in the renal vein and septic emboli in the lungs: A rare presentation. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 19];25:1086-7. Available from: http://www.sjkdt.org/text.asp?2014/25/5/1086/139948
To the Editor,

Emphysematous pyelonephritis (EPN) is a gas-producing necrotizing infection of the kidneys. We describe a 67-year-old male who was detected to have air in the collecting system of the left kidney along with air in the left renal vein and multiple septic emboli in the lungs on imaging, an unusual complication of EPN. The patient presented with high-grade fever (up to 104°F) for one month and oliguria for the last two days. He had a pulse rate of 90/min, his blood pressure was 140/80 mm Hg and he was febrile (103°F). Investigations showed hemoglobin of 5.6 mg/dL, total leuko­cyte count of 22,000/mm 3 , blood urea of 404 mg/dL and creatinine of 7.6 mg/dL. The pa­tient had very high potassium value (8.5 mEq/L), while his sodium and chloride levels were normal. On examination, he had left renal angle tenderness.

Ultrasound examination showed moderate left hydronephrosis with mobile echogenic foci having dirty distal acoustic shadowing suspi­cious of air foci in the dilated pelvi-calyceal system (PCS). A non-contrast computed tomo­graphy (CT) scan of the abdomen showed air foci in the dilated PCS of the left kidney. In addition, air foci were also seen in the left renal vein [Figure 1]a and b. The included lower sections of the lungs showed multiple small nodules along the periphery, some of them showing evidence of breakdown, sugges­tive of septic emboli [Figure 2]. The patient succumbed to cardiac arrest within a few hours of admission and died.
Figure 1: Coronal oblique multiplanar reformatted (MPR) image showing air foci in the collecting system of the left kidney (thin arrows) and the left renal vein (thick arrow) (A). Axial MPR image (wide window setting) demonstrating the same (B).

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Figure 2: Axial section (lung window) showing multiple small nodules (thin arrows) in bilateral lung fields with breakdown in one of the nodules (thick arrow).

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EPN is a life-threatening infective condition characterized by the presence of gas within the renal parenchyma, collecting system or the peri-nephric tissues. Poor glucose control in diabetics creates a favorable environment for bacteria to grow and produce gas. [1],[2]

The gold standard for the diagnosis is CT scan of the abdomen, which shows the pre­sence and extent of the spread of the gas, extent of parenchymal destruction as well as associated collections.

Unusual presentations include pneumome-diastinum and subcutaneous emphysema [3] as well as septic emboli in distant organs. Bhatt et al suggested that the infected gas bubbles enter the blood stream and seed the various organs. [4]

Our patient had septic emboli in the lungs, which has been previously described in only one case report. [4] Air foci were seen in the left renal vein, indicating the dissemination of the infection. The spread occurred thereby through the inferior vena cava to the right side of the heart and into the pulmonary arteries. This radiological finding supports the mechanism proposed by Bhatt et al. [4] In its severe form, EPN can ultimately lead to septic shock and multi-organ failure, with a high mortality rate varying from 20% to more than 80%. [5] Our patient also succumbed to car­diac arrest within a few hours of admission and could not be revived.

In conclusion, EPN is a severe life-threate­ning infection with a poor prognosis. Detection of air in the vasculature with associated septic emboli in the distant organs should be consi­dered an ominous finding.

Conflicts of interest: None

 
   References Top

1.Kelly HA, MacCallum WG. Pnematuria. JAMA 1898;31:375-81.  Back to cited text no. 1
    
2.Mohsin N, Budruddin M, Lala S, Al-Taie S. Emphysematous Pyelonephritis: A case report series of four patients with review of literature. Ren Fail 2009;31:597-601.  Back to cited text no. 2
    
3.Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcuta­neous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol 2004;11:909-11.  Back to cited text no. 3
    
4.Bhatt B, Bhavsar B, Senanayke S, Maloney D, Berger J, Bengualid V. Bilateral emphyse-matous pyelonephritis with multiple septic emboli to brain, lungs, and liver as an initial presentation of new onset diabetes mellitus. NY Med J 2006. Available from: http://newyorkmedicaljournal.org/Archives/bh att4-06.htm. [Last accessed on August 5, 2014].  Back to cited text no. 4
    
5.Flores G, Nellen H, Magana 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. 5
    

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Correspondence Address:
Dr. Mukesh K Yadav
Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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DOI: 10.4103/1319-2442.139948

PMID: 25193916

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