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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 764-768
Emphysematous pyelonephritis presenting as a sonologically absent kidney


1 Department of Nephrology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
2 Department of Radiology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

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Date of Web Publication8-Jul-2015
 

   Abstract 

Emphysematous pyelonephritis is an acute necrotizing infection of the kidney caused by gas-producing organisms. It is being increasingly recognized as an underlying cause of sepsis. We present a case of emphysematous pyelonephritis where the affected kidney was filled with extensive gas. This made the detection of the kidney difficult by ultrasound. Also, this case presents the dilemma of managing a septic patient medically and the risks entailed in surgical intervention in such cases. Most often, these patients have underlying diabetes mellitus with underlying co-morbidities, making indicated surgical management difficult as illustrated by our patient.

How to cite this article:
Patel C, Anandh U, Shah A, Malghan R. Emphysematous pyelonephritis presenting as a sonologically absent kidney. Saudi J Kidney Dis Transpl 2015;26:764-8

How to cite this URL:
Patel C, Anandh U, Shah A, Malghan R. Emphysematous pyelonephritis presenting as a sonologically absent kidney. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Aug 18];26:764-8. Available from: https://www.sjkdt.org/text.asp?2015/26/4/764/160209

   Introduction Top


Emphysematous pyelonephritis is an acute necrotizing infection of the renal parenchyma resulting in the presence of gas either in the collection system or in the peri-nephric space. The first case of gas-forming renal infection was reported in 1898 by Kelly and MacCullum. [1]

Emphysematous pyelonephritis is a severe, potentially fatal illness that presents with variable clinical picture ranging from mild abdominal pain to septic shock. The majority of cases occur in diabetics with poor glycemic control. A small percentage of patients have urinary tract obstruction as the underlying cause of their emphysematous pyelonephritis. [2],[3]

Ultrasound examination of the affected kidneys is not a sensitive investigation in detecting the presence of gas in the genitourinary system, but it is effective in detecting urinary tract obstruction, which is often seen in these patients. Plain computed tomography (CT) scan is the imaging modality of choice. [4]

The current management of these patients includes the use of intravenous antibiotics and external drainage. However, some patients need surgical removal of the kidney because of the severity of their illness and/or because of inadequate response to medical management. [4],[5]

We present a patient with emphysematous pyelonephritis who presented with urosepsis. The presence of air in the left kidney made detection of the kidney by ultrasound difficult. Her initial ultrasound investigation failed to detect the presence of the left kidney. She was initially managed with intravenous antibiotics and percutaneous drainage as she had major cardiac co-morbidities, but eventually she needed surgical removal of the affected kidney.


   Case Report Top


A 49-year-old female, a known case of diabetes mellitus managed with oral hypoglycemic agents for nine years, was admitted to our hospital with complaints of high-grade fever with chills, abdominal pain, vomiting and dysuria of four days duration. She was investigated in another hospital and was found to have anemia, leukocytosis and thrombocytopenia. Her urine analysis revealed the presence of leukocyturia and the culture grew E. coli. The ultrasound study of the abdomen showed absence of left kidney and a normal sized right kidney. There was no evidence of urinary tract obstruction.

Physical examination revealed no pallor, no icterus and no ankle edema and her blood pressure was recorded as 100/40 mm Hg. Her systemic examination revealed the presence of a distended abdomen with left renal angle tenderness. Laboratory investigations [Table 1] showed elevated total leukocyte count, thrombocytopenia, hyponatremia, hypokalemia, renal insufficiency and hypo-albuminemia. The liver enzymes were normal. Her coagulation profile was abnormal with raised activated partial thromboplastin time, prothrombin time and fibrinogen levels. The presence of fibrin degradation products was detected. Smear for malarial parasite, dengue NS1 antigen/dengue IgM and Leptospira IgM were negative. Urine analysis revealed urinary tract infection with E. coli as the pathogenic bacteria. Blood culture revealed the presence of E. coli. She was started on appropriate intravenous antibiotics. Echocardiography of the heart showed systolic dysfunction (ejection fraction 30%). Ultrasound of the abdomen showed poorly visualized left renal parenchyma; the left kidney was completely surrounded by air, which made sonological detection of the left kidney difficult. The right kidney was normal in size with focal cortical scarring. CT scan of the abdomen revealed the presence of left-sided significant pyelonephritis with air extension into the retro-peritoneum [Figure 1]. She was referred to the urologist and was advised left percutaneous nephrostomy, which was subsequently performed [Figure 2].
Figure 1: Computerized tomographic scan of the abdomen showing extensive gas formation in the left kidney.

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Figure 2: Nephrostomy drainage of the affected kidney.

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Table 1: Hematological and biochemical findings in the study patient.

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Percutaneous nephrostomy fluid was evaluated and showed the growth of E. coli. Radionuclide renal scans were performed to determine the renal function of both kidneys. A technetium 99 (Tc99) diethylene-triaminepenta-acetate (DTPA) renal scan (renogram) showed no demonstrable/visible functioning cortical parenchyma in the left renal fossa; even a delayed scan could not delineate the outline of the left kidney [Figure 3]. The right kidney showed suboptimal parenchymal extraction of tracer with a calculated glomerular filtration rate of 27 mL/min. A Tc99 dimercapto succinic acid (DMSA) renal scan showed the presence of sub-optimally functioning left kidney [Figure 4] with large cortical defect involving the lateral border. The right kidney showed cortical scars. The radiological investigations are summarized in [Table 2]. The patient was managed with antibiotics and percutaneous drainage. After initial stabilization for five days, she started showing signs of recurrent sepsis. As the investigations revealed a poorly functioning left kidney, the surgeons decided to perform a left nephrectomy after discussing the operative risks with the relatives. The histopathology of the kidney showed presence of necrotizing pyelonephritis [Figure 5].
Figure 3: DTPA renogram showing sub-optimal function of the left kidney.

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Figure 4: DMSA scan showing minimal renal function in the left kidney.

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Figure 5: Histopathological examination of the nephrectomy specimen showing extensive pyelonephritis.

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Table 2: Radiological findings in the study patient.

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   Discussion Top


Emphysematous pyelonephritis often presents with variable clinical presentation ranging from abdominal pain to septic shock. According to Huang and Tseng, [2] fever was encountered in 79% of patients, abdominal or back pain in 71%, nausea and vomiting in 17%, lethargy and confusion in 19%, dyspnea in 13% and shock in 29% of patients. These patients are initially imaged by ultrasound, which has high diagnostic accuracy. Gas appears as echogenic foci with "dirty" shadowing in the non-dependent position. The appearance can change with the position of the patient. [6] The initial ultrasound in our patient showed absence of the affected kidney because of air (gassed-out kidney). [7] CT scan of the abdomen picked up the emphysematous destruction of the kidney. Wan et al have suggested two stages of emphysematous pyelonephritis for prognostic and therapeutic purposes. [8] Type I included patients showing parenchymal destruction with streaky or mottled gas but with no fluid collection. These patients had a mortality rate of 69%. Type II patients had renal or perirenal fluid collection that contained bubbly or loculated air in the collecting system. The mortality in this group was less (18%). Our patient fell into the first category and had initial poor prognosis. Huang and Tseng et al in their paper have defined four classes of emphysematous pyelonephritis. In class 1, gas was limited to the collecting system. In class 2, gas was present in the renal parenchyma without extension to the extrarenal space. In class 3A, gas extended to the peri-nephric space and in class 3B it was also present in the pararenal space. Class 4 was referred to as bilateral emphysematous pyelonephritis or a solitary kidney with emphysematous pyelonephritis. Our patient had air in the para-renal space and hence was considered as class 3A. [9]

Over the recent years, many reports emphasizing the conservative management of emphysematous pyelonephritis have appeared in the literature. [10] However, it is prudent to consider surgical intervention if a patient presents with severe disease and does not improve with external drainage, as was done in our case. Our patient also had significant cardiac co-morbidity, which was also an important factor that made the treating team consider a conservative approach. Our case highlights the increasing presence of various co-morbidities in Indian diabetic patients, which often makes surgical interventions in life-threatening infections highly risky.

To conclude, emphysematous pyelonephritis is a severe form of necrotizing infection of the renal parenchyma that presents with variable clinical and radiological presentation. Presence of extensive air in the kidney can make sonological detection of the kidney difficult, as was seen in our case. Initial medical management may be attempted; however, surgical intervention is the definitive management if the patient does not improve with medical measures.

 
   References Top

1.
Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol 1984;131:203-8.  Back to cited text no. 1
[PUBMED]    
2.
Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 2
    
3.
Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: A 15-year experience with 20 cases. Urology 1997;49: 343-6.  Back to cited text no. 3
    
4.
Stone SC, Mallon WK, Childs JM, Docherty SD. Emphysematous pyelonephritis: Clues to rapid diagnosis in the Emergency Department. J Emerg Med 2005;28:315-9.  Back to cited text no. 4
    
5.
Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: A 5-year experience with 13 patients. J Urol 1985;134:1086-8.  Back to cited text no. 5
[PUBMED]    
6.
Hui SY, Cheung CW, Hui KT, She HL. Sonographic diagnosis of emphysematous pyelo-nephritis in a clinically stable patient. Hong Kong Med J 2010;16:319.  Back to cited text no. 6
    
7.
Abed El Rahman D, Zanetti G, Ferruti M, et al. Emphysematous pyelonephritis in decompensated diabetes: A case report and review of the literature. Arch Ital Urol Androl 2011;83:108-11.  Back to cited text no. 7
    
8.
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. 8
    
9.
Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ. Host and bacterial virulence factors predisposing to emphysematous pyeloneph-ritis. Am J Kidney Dis 2005;46:432-9.  Back to cited text no. 9
    
10.
Dubey IB, Agrawal V, Jain BK. Five patients with emphysematous pyelonephritis. Iran J Kidney Dis 2011;5:204-6.  Back to cited text no. 10
    

Top
Correspondence Address:
Urmila Anandh
Department of Nephrology, Kokilaben Dhirubhai Ambani Hospital, Four Bungalows, Andheri (West) Mumbai 400 053, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.160209

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]

This article has been cited by
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Visual Journal of Emergency Medicine. 2020; 21: 100890
[Pubmed] | [DOI]



 

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