Successful Conservative Treatment of Emphysematous Pyelonephritis in a Diabetic Patient

1. Palwasha Gul

2. Zeenat Gul

1. PGR Diagnostic Radiology, Combined Military Hospital Quetta 2. PGR General Medicine, BMCH Quetta

ABSTRACT

Emphysematous pyelonephritis is an uncommon condition, with severe potentially fatal necrotizing pyelonephritis due to gas producing organisms (generally gram negative bacilli, esp. E. coli, proteus, pseudomonas, enterobacter and klebsiella).It occurs usually in elderly diabetics with poor glycemic control and frequently associated with ureteric obstruction. Though most of the patients still require nephrectomy albeit improvement in medical treatment, we present a case of successful conservative treatment of emphysematous pyelonephritis in a diabetic patient.

Key Words: Emphysematous pyelonephritis, nephrectomy.


INTRODUCTION

Emphysematous pyelonephritis is a rare condition in which gas develops inside the kidney, perinephric space and/or urinary collecting system. Computed tomogram is gold standard for diagnosis. The Hallmarks of the disease are high grade fever, leukocytosis, renal parenchymal necrosis with exudative material ,accumulation of fermentation gases within the dilated renal collecting system. Till mid 1980s the standard treatment was nephrectomy because preserving the kidney led to mortality of 60-80%.This situation improved over the last few decades with early CT diagnosis and advances in multi disciplinary care of sepsis and multiorgan dysfunction with mortality of 20-25%. Renal emphysema may also be caused by iatrogenic causes (catheterization, retrograde pyelography etc.) or fistulous communication to the skin or a gas-containing viscous. Although there are reports of improved renal functions after medical therapy combined with relief of obstruction by uretero pelvic stenting of drainage of pent-up collections, but most of the patients still require nephrectomy.1,2,3

CASE REPORT

A 38 years old male presented with left lumber pain, low grade fever, dysuria and shortness of breath. On physical examination blood pressure was 145/85mmHg, pulse 100/min, respiratory rate 20/min, and temperature 101F.

On auscultation there were decreased breath sounds on left side. CVS was unremarkable. Laboratory investigations showed hemoglobin 12.6gram/dl, leucocytes 11.1x109/L, neutrophils 90%, lymphocytes 20%,eosinophil’s2%, monocytes 3%, PLT 80x109/L, serum urea 13.8mmol/L, serum creatinine 140umol/L. Urine microscopy and biochemistry showed albumin 1+, sugar 1+, and numerous pus cells. X ray plain abdomen showed radiolucent streaks overlying the renal fossa (Figure 1).

  

Figure No.1: X ray plain abdomen showed radiolucent streaks

verlying the renal fossa with radio opaque calculus in lower pole

of kidney and ureteric line (left)

Left kidney could not be visualized on ultrasound abdomen. CT scan KUB showed acute emphysematous pyelonephritis (type 1) on left side with extension of air lucencies into retro peritoneum, left proximal ureter and left renal vein (Figure 2). Patient was kept on conservative treatment because he was stable and improved with the medical treatment successfully.


Figure No.2: CT scan KUB showed acute emphysematous

pyelonephritis (type 1) on left side with renal calculus  

DISCUSSION

Empysematous pyelonephritis is a life threatening necrotising pyelonephritis with variable clinical presentation, ranging from mild abdominal pain to septic shock. The majority of cases occur in diabetics with poor glycemic control while a small percentage is due to urinary tract obstruction.4

It is mostly reported in elderly patients but our patient is young. Gaither K et al2 reported 37 years old female with 7 year history of nephrolithiasis and pyelonephritis. She was diagnosed with EPN. She was also six weeks pregnant. Drainage of left pyonephrosis and stenting was done later. Patient was discharged on 8th post operative day but she never returned for
follow up.

On ultrasonography we could not visualize left kidney initially and also not on repeat sonogram. Rauf AA5 et al reported a case with unremarkable renal sonogram but two days later visualized right kidney could not be seen. EPN was confirmed on CT and repeat Xray.

The majority of cases of EPN reported occur in diabetics and urinary tract obstruction. Dubey IB et al6 reported EPN in non diabetic patient with non obstructed kidney.

Jaisuresh K7 had a successful conservative treatment of bilateral EPN patient with autosomal dominant polycystic kidney disease. Percutaneous needle aspiration of infected cyst was done and antibiotics were given.

Morioka H et al8 reported a case with bilateral EPN who also had a splenic abscess.

EPN is a life threatening condition. Over years nephrectomy had been treatment of choice but due to advances in medical care and multidisciplinary approach, conservative treatment saves the kidneys and so do the patient.

REFERENCES

1.       Sutton D. The kidneys and ureters. Text book of radiology and imaging. 7th ed.UK; 2003.p.929-987.

2.       Gaither K, Ardite A, Mason TC. Pregnancy complicated by emphysematous pyelonephritis. J Nati Med Assoc 2005;97(10):1411-3.

3.       Fatima R, Jha R, Muthukrishnan J, Jude D, Nath V, Shekhar S, Narayan G, et al. Ind J Nephrol 2013; 23(2):119-24.

4.       Archana S, Vijaya C, Geetathamani V, Savitha AK. Emphysematous pyelonephritis in a diabetic leading to renal destruction: pathological aspects of a rare case. Malays J Pathol 2013;35(1):103-6.

5.       Rauf AA, Shanaah A, Joshi A, Popli S, Vaseemuddin M, Inq TS. Failure of sonography to visualize a kidney affected by emphysematous pyelonephritis. Ind J Urol 2007;23(2):200-2.

6.       Dubey IB, Agrawal V, Jain BK, Prasad D. Empysematous pyelonephritis in a non diabetic patient with non-obstucted kidney:an unknown entity. Saudi J kidney Dis Transpl 2013;24(1):97-9.

7.       Jaisuresh K, Bavaharan R. Successful conservative treatment of bilateral emphysematous pyelonephritis in autosomal dominant polycystic kidney disease. Ind J Nephrol 2013;23(3):229-31.

8.       Morioka H, Yanaqisawa N, Suqanuma A, Imamura A, Ajisawa A. Bilateral empysematous pyelonephritis with splenic abscess. Intern Med 2013;52(1):147-50.

 

Address for Corresponding Author:

Dr. Palwasha  Gul,

Post Graduate Resident,
Diagnostic radiology, Combined Military
Hospital Quetta.

Address: C-4, Kabir building MA Jinnah road, Quetta.

Cell: 03003884472

 

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