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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 706-709
Gas in the kidney in asymptomatic Escherichia coli urinary tract infections in a patient with severe vesicoureteral reflex


1 Department of Renal Medicine, Royal Hospital, Muscat, Oman
2 Department of Urology, Royal Hospital, Muscat, Oman
3 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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Date of Submission29-May-2018
Date of Acceptance11-Jul-2018
Date of Web Publication26-Jun-2019
 

   Abstract 


Diabetes mellitus (DM) is a common disease in Oman as in rest of Gulf Cooperation Council where metabolic syndrome is of high prevalence. DM is a foremost risk factor for urinary tract infections (UTIs). It is also linked to more complicated infections such as emphysematous pyelonephritis (EPN), emphysematous pyelitis (EP), renal/perirenal abscess, emphysematous cystitis, xanthogranulomatous pyelonephritis, and renal papillary necrosis. The diagnosis of these cases is frequently delayed because the clinical manifestations are generic and not different from the typical triad of upper UTI, which include fever, flank pain, and pyuria. A middle-aged female with DM and chronic kidney disease stage IV was admitted with recurrent UTI with extended-spectrum beta-lactamase-producing Escherichia coli. At presentation, she was afebrile, clinically stable, had no flank pain and there was no leukocytosis. Laboratory test for C- reactive protein done twice and was only mildly elevated at 7 and 11 mg/dL. A computed tomography scan of kidney-ureter-bladder (CT-KUB) was recommended and reported as “no KUB stone but small atrophic left kidney with dilatation of the pelvicalycial system and ureter and the presence of air in the collecting system suggestive of EP.” Thus, commonly associated with DM, especially in females, debilitated immune-deficient individuals, and patients harboring obstructed urinary system with infective nidus. Air in the kidney is not always due to EPN. UTI with a gas-producing organism can ascend to the kidney in the presence of vesicoureteral reflux.

How to cite this article:
Pakkyara A, Jha A, Al Salmi I, Mohammed E, Jothi V, Al Lawati S, al Maamari S, Faisal FA. Gas in the kidney in asymptomatic Escherichia coli urinary tract infections in a patient with severe vesicoureteral reflex. Saudi J Kidney Dis Transpl 2019;30:706-9

How to cite this URL:
Pakkyara A, Jha A, Al Salmi I, Mohammed E, Jothi V, Al Lawati S, al Maamari S, Faisal FA. Gas in the kidney in asymptomatic Escherichia coli urinary tract infections in a patient with severe vesicoureteral reflex. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 12];30:706-9. Available from: http://www.sjkdt.org/text.asp?2019/30/3/706/261351



   Introduction Top


Diabetes mellitus (DM) is a common disease in Oman as in rest of Gulf Cooperation Council where metabolic syndrome is of high prevalence. DM is a foremost risk factor for urinary tract infections (UTIs) and is also connected with increased risk of UTIs. It is also linked to more complicated infections such as emphy-sematous pyelonephritis (EPN), emphysema-tous pyelitis (EP), emphysematous cystitis, xanthogranulomatous pyelonephritis, renal/ perirenal abscess, and renal papillary necrosis. The diagnosis of these cases is often delayed because the clinical manifestations are nonspecific and not different from the classic triad of upper UTI (i.e., fever, flank pain, and pyuria).

Various nomenclatures have been used interchangeably for this gas-forming infective disorder including: pneumonephritis, renal emphysema, and EPN. Gas in the nephron-urology system is commonly associated with DM, especially in females, incapacitated immune-deficient patients, and those harboring obstructed urinary system with infective nidus. Gram-negative facultative anaerobic microorganisms such as  Escherichia More Details coli (E. coli) are responsible for the production of gas through the fermentation of glucose. In the usual triad features of pyelonephritis, EPN is diagnosed by computed tomography (CT) scan. However, in the absence of these features, the presence of gas in the urinary system has not been reported. Hence, we report a female patient, who was afebrile, clinically stable, had no flank pain, and there was no leukocytosis while the C-reactive protein (CRP) mildly raised.


   Case Report Top


A middle-aged female with DM and chronic kidney disease Stage IV was admitted with recurrent UTI with extended-spectrum beta-lactamase-producing E. coli (ESBL – E. coli). An ultrasonogram of kidney-ureter-bladder (KUB) showed left renal hyperechoic foci that could be stones rather than air densities. A CT scan of KUB was recommended and reported as “no KUB stone but small atrophic left kidney with dilatation of the pelvicalyceal system (PVS) and ureter and the presence of air in the collecting system suggestive of EP” [Figure 1]. However, the patient was afebrile, clinically stable, had no flank pain, and there was no leukocytosis. CRP done twice was only mildly elevated at 7 and 11 mg/dL. Hence, it was postulated that the presence of air in the left kidney might be as consequence of air ascending from the bladder due to possible vesicoureteral reflux (VUR). A mictu-rating cystourethrogram was performed which showed Grade IV VUR on the left side [Figure 2].
Figure 1: Computerized tomography of kidney-ureter-bladder showing air in the left kidney.

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Figure 2: Micturating cystourethrogram showing vesicoureteral reflex.

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   Discussion Top


This is the first report of an air in the kidney that occurred in the setting of UTI with a gas producing organism which ascends to the kidney in the presence of VUR but not due to EPN. Complicated UTIs are common and potentially life-threatening conditions in diabetic patients. Early diagnosis, knowledge of common predisposing factors, appropriate clinical and radiological assessment, and prolonged course of appropriate antibiotherapy are the mainstay of multifactorial management approach strategy to improve prognosis.

It has been reported that high tissue glucose levels in an immunocompromised patient, such as a diabetic patient, can lead to infection with glucose-fermenting bacteria or yeast.[1] Fermentation of glucose within the urinary tract leads to the formation of H2 and CO2 gas within the urinary tract and within the luminal mucosa.[2] Various factors are involved in the pathogenesis of the gas formation, such as high levels of glucose within the tissues, the presence of gas-forming microorganisms, reduced vascular blood supply, impaired host immunity and the presence of obstruction within the urinary tract.[2],[3] A high level of tissue glucose in association with reduced blood supply to the kidneys, which is prevalent in patients with diabetes, facilitates the development of anaerobic metabolism.

The utmost precise way for the diagnosis and monitoring of gas-containing infections of the urinary system in humans is CT.[4] CT helps to eliminate complicated EP, such as the presence of kidney or perirenal fluid collections, abscesses, or EPN. Moreover, CT can rule out other causes of urinary gas such as vesicocolic fistula. CT scan discriminates between the presence of gas bubbles within the pelvi-calyceal system, the kidney parenchyma, and/or the perinephric space.[5]

A radiological classification the gas in the kidney has been proposed based on its location: class 1: gas limited to the collecting system of the kidney, class 2: gas confined to the kidney parenchyma, class 3A: perinephric extension of gas or abscess, class 3B: extension of gas outside the Gerota fascia and class 4: bilateral or EPN in a solitary kidney.[6]

In 1898, Kelly and MacCullum reported the first case of gas-forming kidney infection.[7] Later, terms such as renal emphysema, pneu-monephritis, and EPN were used to describe the gas-forming infection. Schultz and Klorfein in 1962, recommended the use of EPN to emphasize the relationship between infective pathology and gas formation.[8]

EPN is an acute severe necrotizing infection of the kidney parenchyma and its surrounding tissues that results in the presence of gas in the kidney parenchyma, collecting system or perinephric tissue.[9] There is a majority of EPN occurs in females; the female:male ratio reported in relatively small studies is 6:1.[9] Increased susceptibility to UTI appears to be the cause for the higher incidence in females.[10] The risk of developing EPN secondary to a urinary tract obstruction is «25 %–40%.[10] Furthermore, it seems to be geographically more common in Asia. DM is the single most common associated factor. Up to 95% of patients with EPN have underlying uncontrolled DM.[9] Furthermore, other factors associated with the development of EPN are drug abuse, neurogenic bladder, alcoholism, and anatomic anomaly.[9],[10]

Gram-negative facultative anaerobic microorganisms such as E. coli are accountable for the making of gas through the fermentation of glucose and lactate.[11] This process results in the production of high levels of carbon dioxide and hydrogen which accumulate at the location of inflammation. Furthermore, nitrogen and oxygen have been found along with traces of ammonia, methane, and carbon monoxide.[12] Gas may extend beyond the site of inflammation to the subcapsular, perinephric, and pararenal spaces.[9],[13] Further, gas was found to be even extending into the scrotal sac and spermatic cord.[9],[13] Past antibiotic treatment is a recognized risk factor for third-generation cephalosporin-resistant Enterobacteriaceae.[14] ESBL-producing or Amp-C harboring isolates should be considered.[14] Initial optimal treatments are also apt to be inadequate for patients with bacteremia due to ESBL producers, with devastating impact on clinical outcomes.[15]

In conclusion, air in the kidney is not always due to EPN. UTI with a gas producing organism can ascend to the kidney in the presence of VUR. Most commonly caused by E. coli and Klebsiella pneumoniae and characterized by the occurrence of gas in the kidney system. DM, urinary obstruction, and calculus help as niduses of infection, and provide oppurtune place for fulminant infection. CT scan is the mainstream choice to outline the spreading of gas, disease extension. Management requires multidisciplinary teamwork including hydration and electrolyte management, broad-spectrum antibiotics, excellent blood sugar control, active urinary drainage, and finally may require emergency nephrectomy as salvage surgical management strategy.

Conflict of interest: None declared.



 
   References Top

1.
Peleg AY, Weerarathna T, McCarthy JS, Davis TM. Common infections in diabetes: Pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev 2007;23:3-13.  Back to cited text no. 1
    
2.
Yang WH, Shen NC. Gas-forming infection of the urinary tract: An investigation of fermentation as a mechanism. J Urol 1990;143:960-4.  Back to cited text no. 2
    
3.
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. 3
    
4.
Hiorns MP. Imaging of the urinary tract: The role of CT and MRI. Pediatr Nephrol 2011;26:59-68.  Back to cited text no. 4
    
5.
Hiremath R, Mahesh, Padala KP, Swamy K, Pailoor A. A rare case of pneumoureter: Emphysematous pyelitis versus emphyse-matous pyelonephritis. J Clin Diagn Res 2015; 9:TD03-5.  Back to cited text no. 5
    
6.
Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 6
    
7.
Kelly HA, MacCallum WG. Pnematuria. JAMA 1898;31:375-81.  Back to cited text no. 7
    
8.
Schultz EH Jr., Klorfein EH. Emphysematous pyelonephritis. J Urol 1962;87:762-6.  Back to cited text no. 8
    
9.
Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int 2011;107:1474-8.  Back to cited text no. 9
    
10.
Al-Badr A, Al-Shaikh G. Recurrent urinary tract infections management in women: A review. Sultan Qaboos Univ Med J 2013; 13:359-67.  Back to cited text no. 10
    
11.
Förster AH, Gescher J. Metabolic engineering of Escherichia coli for production of mixed-acid fermentation end products. Front Bioeng Biotechnol 2014;2:16.  Back to cited text no. 11
    
12.
Cummins EP, Selfridge AC, Sporn PH, Sznajder JI, Taylor CT. Carbon dioxide-sensing in organisms and its implications for human disease. Cell Mol Life Sci 2014; 71:831-45.  Back to cited text no. 12
    
13.
Frias Vilaça A, Reis AM, Vidal IM. The anatomical compartments and their connections as demonstrated by ectopic air. Insights Imaging 2013;4:759-72.  Back to cited text no. 13
    
14.
Rawat D, Nair D. Extended-spectrum β- lactamases in gram negative bacteria. J Glob Infect Dis 2010;2:263-74.  Back to cited text no. 14
    
15.
Lee NY, Lee CC, Huang WH, Tsui KC, Hsueh PR, Ko WC. Carbapenem therapy for bacteremia due to extended-spectrum-β-lactamase-producing Escherichia coli or Klebsiella pneumoniae: Implications of ertapenem susceptibility. Antimicrob Agents Chemother 2012; 56:2888-93.  Back to cited text no. 15
    

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Correspondence Address:
Issa Al Salmi
Department of Renal Medicine, Royal Hospital, Muscat
Oman
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DOI: 10.4103/1319-2442.261351

PMID: 31249237

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    Abstract
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    References
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