Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis

Emphysematous pyelonephritis caused by candida species: A case report and outcome of 1 year follow-up

Emphysematous pyelonephritis (EPN) is an acute life-threatening gas-forming necrotizing infection of the renal parenchyma and its surrounding tissues. EPN requires early diagnosis and management because of related life-threatening septic complications. Gram-negative bacteria remain the most common causative organisms.

Although candida species as a causative pathogen in emphysematous pyelonephritis is very rare, we report a rare case of emphysematous pyelonephritis caused by candida species successfully managed with unilateral nephrectomy and outcome for flow up in one year.

Diabetic ketoacidosis complicated by emphysematous pyelonephritis: a case report and literature review

Background

The management of emphysematous pyelonephritis (EPN) includes conservative medical treatment, percutaneous drainage, and surgical resection of the involved kidney. EPN with diabetic ketoacidosis(DKA) is very rare, in which the clinical management of refusing surgical drainage is inexperienced.

Case presentation

A 34-year-old woman presented with abdominal pain, chills, fever, nausea, vomiting, chest tightness, and shortness of breath. Blood test results were consistent with diabetic ketoacidosis. Urinary computed tomography scan showed multiple stones in the right kidney and lower ureter, with right hydronephrosis. Blood culture demonstrated Escherichia coli bacteremia, and EPN was diagnosed. Considering the need for a second percutaneous nephrolithotomy, the patient refused percutaneous drainage. After continuous intravenous infusion of small doses of insulin and antibiotic treatment, the ketoacidosis resolved. The patient’s temperature returned to normal and abdominal pain was alleviated, and liver and kidney functions were also back to normal. After hospital discharge, the patient underwent two percutaneous nephrolithotomy in the department of urology.

Conclusions

EPN with diabetic ketoacidosis should be diagnosed as soon as possible. For patients with Class 1 and Class 2 EPN with diabetic ketoacidosis and urinary tract obstruction, if surgical drainage is refused, it is particularly important to rapidly correct diabetic ketoacidosis and intravenous use of sensitive antibiotics, so as to create conditions for follow-up percutaneous nephrolithotomy.

Acute Renal Infection in Adult, Part 2: Emphysematous Urinary Tract Infection—What the Radiologist Needs to Know

Renal emphysema, as described by Kelly and MacCallum in 1898, refers to the spontaneous generation of gas within the renal parenchyma and surrounding tissues. Since its initial description, it has become apparent that the spectrum of radiologically visible renal and perirenal gas includes three distinct clinical entities: (1) emphysematous pyelonephritis, a necrotizing infection associated with gas formation in the renal parenchyma, (2) emphysematous pyelitis, in which gas is confined to the renal pelvis and calyces, and (3) gas-forming perinephric abscess. In this article, we will review gas-forming infections of the urinary system in terms of radiological features, clinical manifestations, predisposing factors, and appropriate management guidelines.

Emphysematous Pyelonephritis Caused by a Giant Fecaloma

Emphysematous pyelonephritis (EPN) is a gas-producing necrotizing bacterial infection that involves the renal parenchyma and perirenal tissue. It is a life-threatening condition that requires a high index of suspicion, an early diagnosis and an aggressive treatment. Rapid progression to septic shock may occur. We report, to the best of our knowledge, the first case of obstructive EPN caused by a giant fecaloma. The patient was successfully treated with percutaneous drainage and broad-spectrum antibiotics, in addition to fecaloma evacuation using fleet enemas and oral laxatives. This shows how fecal impaction, a common pathology in routine clinical practice, can cause some serious complications if left untreated, including extrinsic ureteral compression.

Simultaneous Diagnosis of Emphysematous Osteomyelitis and Emphysematous Pyelonephritis in a Diabetic Patient

BACKGROUND Emphysematous osteomyelitis of the spine is characterized by intravertebral or intraosseous air. Emphysematous pyelonephritis (EP) is the infection of the renal parenchyma and perirenal tissues caused by gas forming microorganisms and thus is characterized by gas formation. Prompt diagnosis and initiation of necessary treatment is crucial, as both entities are associated with high mortality rates. CASE REPORT A 57-year-old female with uncontrolled hyperglycemia presented to the emergency department with history of sudden onset of weakness, nausea, vomiting and diarrhea for 3 days and with a fall on the same level the previous day. Laboratory examinations revealed leukocytosis, lymphopenia, thrombocytopenia, deteriorated renal function, and hyperglycemic hyperosmolar non-ketotic state. She was placed on aggressive intravenous hydration and insulin infusion pump. Due to the deterioration of her medical condition, she underwent abdominal and pelvic CT scanning that revealed emphysematous osteomyelitis of the spine and emphysematous pyelonephritis. Despite vigorous fluid resuscitation and systemic broad-spectrum antibiotic therapy, the patient's condition deteriorated further and eventually led to death within 48 h. CONCLUSIONS This case of fatal emphysematous osteomyelitis of the spine and EP serves as a significant reminder of those rare life-threatening entities, which affect patients with comorbidities, such as diabetes mellitus and other etiologies causing immunosuppression. The aim of the present case report is to highlight the importance and contribution of computed tomography in diagnosing these conditions and to emphasize the rare coexistence of these 2 emphysematous entities.

Emphysematous Pyelonephritis: A single center review

Background and Objective

Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing renal parenchymal infection. Traditional management of EPN with nephrectomy had a mortality of 40-50%. The purpose of this case series was to assess the management, biochemical factors, and outcome of EPN patients.

Methods

In this retrospective study, patients admitted to The Indus Hospital, Karachi with a diagnosis of EPN from January 2010 to February 2019, were grouped according to the Huang Tseng Classification (HTC). Their biochemical parameters, sensorium states and outcomes were recorded and analysed.

Results

Twenty patients were reviewed (9 males). No mortality was recorded. 11 patients (55%) were treated conservatively with only intravenous antibiotics and eight patients underwent an intervention: minimally invasive with drain placement in six patients, and invasive in four patients (two underwent subsequent nephrectomy, and two patients had nephrectomy only). One patient left against medical advice. All patients had decreased serum creatinine levels and total leucocyte counts on discharge.

Conclusion

EPN can be successfully managed conservatively for HTC Grade-1 and 2. Conservative treatment may be tried in higher grades, but poor response should lead to prompt escalation of treatment.

Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients' need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals' emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ² tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.

Renal vein and vena caval thrombus: a rare presentation of emphysematous pyelonephritis

Emphysematous pyelonephritis (EPN) can present with symptoms due to infection or sepsis. EPN presenting with renal vein and inferior vena cava (IVC) thrombus is very rare. We report a case of EPN with renal vein and IVC thrombus and its management.

Emphysematous Pyelonephritis Presenting as Pneumaturia and the Use of Point-of-Care Ultrasound in the Emergency Department

Emphysematous pyelonephritis (EPN) is a rare form of pyelonephritis causing a severe infection of the renal system that includes gas in the renal parenchyma, collecting system and surrounding tissue often presenting with sepsis. We report the case of a 60-year-old male with poorly controlled insulin dependent diabetes mellitus who presented with abdominal pain, nausea, vomiting, and “peeing air.” CT scan revealed air extending from the left renal parenchyma, perinephric fat and into the bladder, consistent with emphysematous pyelonephritis. Bedside point-of-care ultrasound (POCUS) subsequently revealed dirty shadowing and reverberation artifacts in the left kidney and the bladder consistent with gas in the urinary collecting system. By understanding the identifying artifacts seen with EPN, reflective shadow and reverberation artifact, the emergency physician may be alerted to the diagnosis sooner. Often this illness presents similarly to simple, acute pyelonephritis or undifferentiated sepsis. Therefore, POCUS allows for real time consideration of this condition while in the emergency department and thus prompter time to treatment.

Evaluation and Management of Urinary Tract Infection in the Emergency Department

Urinary tract infection (UTI) affects patients of all ages and is a diagnosis that emergency physicians might make multiple times per shift. This article reviews the evaluation and management of patients with infections of the urinary tract. Definitions of asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI are presented, as well as techniques for distinguishing them. The pathophysiology and clinical and laboratory diagnoses of UTI are described. Treatment of UTI is reviewed, with attention to bacteriuria and special populations, including pregnant, elderly/geriatric, and spinal cord injury patients.

A rare case of asymptomatic emphysematous pyelonephritis

Asymptomatic emphysematous pyelonephritis is a rare but potentially life-threatening disease. Diabetes mellitus is the most recognised risk factor. Aim of this case report is to review evidence of emphysematous pyelonephritis to identify risk factors and treatment options.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE

In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification.

METHODS

A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS^®.

RESULTS

Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality.

CONCLUSION

Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Could platelet to leucocytic count ratio (PLR) predict sepsis and clinical outcomes in patients with emphysematous pyelonephritis?

OBJECTIVES

To study risk factors for sepsis and mortality evaluating the role of platelet to leucocytic count ratio (PLR) as a marker for urosepsis and clinical outcomes in cases of emphysematous pyelonephritis (EPN).

MATERIALS

Patients with EPN were retrospectively reviewed. Patients' age, sex, diabetes mellitus (DM), Body Mass Index (BMI), hydronephrosis, types of EPN, air locules volume, serum creatinine, leucocytic count, and platelet count, PLR, albumin, INR and the line of treatment were analyzed as risk factors of sepsis. Correlation between PLR and other variables was done using Pearson correlation coefficient. Univariate and multivariate analyses for sepsis and mortality were performed.

RESULTS

Of fifty four patients, 38 patients had SIRS ≥2 criteria on admission. Twenty patients developed sepsis requiring ICU admission. In univariate analysis, male gender, lower BMI, higher INR, higher WBCs count and lower PLR were associated with sepsis (P = 0.0001, 0.009, 0.04, 0.003 and 0.001, respectively). In multivariate analysis, PLR ≤18.4, male sex and BMI ≤24.2 were independent risk factors. Lower PLR directly correlated with serum albumin (P = 0.01) and inversely correlated with serum creatinine and random blood glucose level and Klebsiella infection (P = 0.001, 0.007 and 0.005, respectively). Also, it was correlated with a higher total score of qSOFA and SOFA (P = 0.02 and 0.04). Lower PLR was independent risk factors for death in EPN patients with (P = 0.003).

CONCLUSION

EPN is associated with sepsis development. Lower PLR is an independent simple predictor for sepsis and mortality in patients with EPN.

Risk of SOFA Deterioration in Conservative Treatment for Emphysematous Pyelonephritis: Pitfalls of Current Trends in Therapeutics from Multicenter Clinical Experience

INTRODUCTION

We investigated relationships between therapeutic outcomes of patients with emphysematous pyelonephritis (EPN) and changes in the Sequential Organ Failure Assessment (SOFA) score.

MATERIALS AND METHODS

We retrospectively evaluated EPN patients treated in our hospitals using the SOFA score incorporated in the Sepsis-3 updated in 2016.

RESULTS

Seventeen typical EPN patients were included in this study, and were treated with medical management with no drainage (n = 3), retrograde stenting (n = 10), or percutaneous drainage (n = 3). One patient without drainage died of sepsis, yielding an overall mortality rate of 5.9%. Twelve patients recovered without increase in the SOFA score during hospitalization. However, the SOFA score deteriorated in the other patients from admission, with the initial scores not significantly different from those of the 12 cases. The changes in the SOFA score were significantly affected by the selected approaches of drainage (100% patients for no drainage, 22% for stenting, and 0% for percutaneous drainage, p = 0.029), but not by other clinical data.

CONCLUSION

Most EPN patients can currently be conservatively managed successfully. However, it should be noted that less-invasive management could cause deterioration in SOFA after admission, yielding a risk of septic mortality.

Neutrophil:Lymphocyte Ratio as a Predictive Factor for Success of Nephron-Sparing Procedures in Patients with Emphysematous Pyelonephritis

INTRODUCTION

We studied the value of neutrophil:lymphocyte ratio (NLR) in predicting the success of nephron-sparing procedures in management of emphysematous pyelonephritis.

METHODS

In this single-center retrospective study, patients underwent nephron-sparing procedures between 2007 and 2014. Severity was graded by Huang-Tseng classification. Thrombocytopenia, acute renal failure (ARF), shock, altered sensorium, and admission NLR were evaluated for predictive value for successful outcomes. Receiver operating characteristic curves were plotted to determine optimal cutoff of NLR for differentiating successful and unsuccessful outcomes. Two-sided p values were calculated with the χ² test. Factors that were significant on univariate analysis were combined in a model with NLR.

RESULTS

Sixteen patients, 14 (87.5%) of whom were female and 14 (87.5%) of whom had diabetes, were included. Ten (63%) had severe emphysematous pyelonephritis. The optimal cutoff of NLR was 5. Four (44%) of 9 patients with NLR above 5 had unfavorable outcomes compared with none of 7 with NLR of 5 or less, giving a risk ratio of 1.8 (95% confidence interval [CI]= 1.01-3.22, p = 0.0417). Area under the curve for NLR alone was 0.77 (95% CI = 0.55-0.99, p = 0.014). High NLR and ARF were the only factors predicting unsuccessful outcome (p = 0.0417 each). When these were combined in a model (NLR as continuous variable), the area under the curve increased to 0.92.

CONCLUSION

NLR is a useful predictive marker in emphysematous pyelonephritis. Its predictive value increases when combined with presence or absence of ARF. In patients with high NLR and ARF, the threshold for considering nephrectomy should be low.

Candida sp. Infections in Patients with Diabetes Mellitus

Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.

Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes?

Objective:

The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients.

Materials and Methods:

The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed.

Results:

The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%.

Conclusion:

Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.

[A CASE OF EMPHYSEMATOUS PYELONEPHRITIS WHO PRESENTED THE PRESERVATION OF THE IPSILATERAL KIDNEY FOLLOWING OPEN DRAINAGE]

We report a case of a 53-year-old woman with emphysematous pyelonephritis who presented the preservation of the ipsilateral kidney following open drainage. She was transferred to our hospital with chief complaints of right back pain and high fever. On diagnosis, diabetes mellitus and a stone in the right ureter were confirmed, and she was followed up at a local clinic. Computed tomography revealed the presence of gas in the right renal pelvis, and the stone led to right hydronephrosis. Additionally, her hemoglobin A1c level was 11.3%. Hence, we diagnosed the patient with emphysematous pyelonephritis. Although right percutaneous nephrostomy was performed immediately after her admission, the gas in the right renal pelvis extended to the renal parenchyma one day later. Therefore, we performed open drainage of the right kidney to control severe inflammation. The gas disappeared after the procedure, and her systemic status gradually improved. We hypothesize that emphysematous pyelonephritis is treated with open drainage instead of nephrectomy while preserving the ipsilateral kidney.

[SUCCESSFUL TREATMENT OF SEVERE EMPHYSEMATOUS CYSTITIS USING RETROPENITONEAL DRAINAGE: A CASE REPORT]

Emphysematous cystitis is a rare disease involving infection caused by gas-producing bacteria is characterized by air storage in the bladder wall and lumen. Approximately 90% of the affected cases are treated using medical therapy alone, and approximately 10% require combined surgical treatment. Here we report a case of emphysematous cystitis with septic shock that could be treated using multimodal therapy with retroperitoneal drainage. A 76-year-old woman was hospitalized at a nearby hospital owing to lumbar compression fracture. She was transferred to our hospital owing to altered consciousness and low blood pressure. She was diagnosed with emphysematous cystitis, and conservative treatment was performed using an indwelling bladder catheter and by administering antibiotics or vasopressors. The patient had septic shock; hence, retroperitoneal drainage was performed. After surgery, the patient's general condition improved. In this study, we review the characteristics of five cases of emphysematous cystitis requiring surgical treatment in Japan.

Emphysematous Pyelonephritis Following Ureterovesical Reimplantation for Congenital Obstructive Megaureter. Pediatric Case Report and Review of the Literature

Introduction: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of the kidney. To date, very few cases of EPN have been described in the pediatric age. The first case of EPN in a toddler occurring after ureterovesical reimplantation for congenital obstructive megaureter is reported with a literature review. Case Report: A 23-month-old male, with a prenatal diagnosis of obstructive megaureter and incomplete duplication of the left urinary tract, was admitted to our Unit where he underwent surgery to treat increased dilatation of the renal pelvis and appearance of an obstructive curve. The latter was revealed at renal scintigraphy, the exam highlighted the radiographic aspect of the cortical renal parenchymal sufferance. At admission preoperative exams were normal, and no recurrent urinary tract infections were documented. Surgical removal of the left stenotic ureteral common tract of the incomplete duplex collecting system was accomplished; ureterovesical reimplantation was performed without ureteral recalibration. No intraoperative complications were recorded. In the immediate postoperative period, urosepsis and the patient's lethargic condition led to life-threatening conditions requiring urgent admission to the intensive care unit. Biochemical analysis showed leukocytosis, anemia, increased C-reactive protein, prolonged prothrombin time, pancytopenia, hyponatremia. Abdominal sonographic evaluation revealed the presence of gas in the left kidney. Unilateral EPN (Class 2) was confirmed by CT- scan. Escherichia coli was cultured from peripheral blood and antimicrobial therapy was started. No additional interventions were required. The child was discharged 14 days postoperatively with normal renal function. Conclusion: EPN is a serious condition that can occur after surgical treatment for urinary tract obstruction. Early detection of air in the kidney should be considered a sign of complicated urinary tract infection. Immediate aggressive resuscitation and antimicrobial therapy are effective and curative with a positive outcome.

Autosomal Dominant Polycystic Kidney Disease with Emphysematous Polycystic Renal Infection That Required Surgical Treatment

We encountered a patient with autosomal dominant polycystic kidney disease (ADPKD) complicated with emphysematous polycystic renal infection (EPRI). A 44-year-old woman visited our hospital for a fever, appetite loss, and gross hematuria. Because the patient was suffering from end-stage renal disease (ESRD), she was immediately hospitalized for hemodialysis. Multiple emphysematous infected cysts were noted in the right kidney, and antibiotic therapy and three rounds of cystic drainage were performed. However, the patient did not respond to treatment. Therefore, laparoscopic right nephrectomy was performed. ADPKD with comorbid EPRI is unresponsive to conservative treatment, and we believe that nephrectomy should be considered.

[Favorable evolution after medical treatment in three cases of emphysematous pyelonephritis: about 3 cases]

La pyélonéphrite emphysémateuse est une infection nécrotique du rein caractérisée par la présence de gaz au sein du parenchyme rénal, des cavités excrétrices ou des espaces péri rénaux. Il s'agit d'une forme grave pouvant engager le pronostic vital. La prise en charge reste controversée: entre l'attitude chirurgicale et le traitement purement médical, il existe une place pour le drainage percutané. Nous rapportons 3 cas de PNE traité par des antibiotiques seuls avec une bonne évolution, nous montrons à travers que le traitement médical pourrait suffire.

A case of bilateral emphysematous pyelonephritis caused by Candida albicans

Emphysematous pyelonephritis (EPN) is a life-threatening renal infection characterized by the formation of gas within the renal parenchyma and collecting duct system, as well as perinephric tissues. We herein report a case of bilateral EPN accompanied by the urinary tract infection caused by spherical growth of Candida albicans in a patient with underlying diabetes mellitus and prostate cancer. The diagnosis was assisted by computed tomography, urography, and gram staining. Despite immediate percutaneous catheter drainage and a 4-week course of antifungal treatment, the C. albicans infection was refractory, as indicated by continuous isolation from the urine, and the patient eventually died. A local autopsy of urinary organs revealed C. albicans in the renal tissue. EPN caused by Candida species frequently occurs in men, and almost all cases have underlying poorly controlled diabetes. This condition is subject to delayed diagnosis, which may lead to extended disease and high mortality. Candida species should be considered as causative microorganism for refractory EPN in patients with poorly controlled diabetes who are receiving antibiotic treatment. Gram staining may contribute to an early diagnosis of EPN caused by Candida species, which may require long-term antifungal therapy.

Emphysematous pyelonephritis and cystitis in a patient with uremia and anuria: A case report and literature review

INTRODUCTION

Emphysematous pyelonephritis (EPN) or cystitis (EC) is a severe infection of the urinary tract with high mortality. EPN is uncommon among the patients of end stage of renal failure (ESRD) CASE PRESENTATION:: A 38-year-old male with uremia and anuria who was on hemodialysis was found to have gas formation in the bilateral pelvis, ureters, and urinary bladder by CT scan. The diagnosis was emphysematous pyelonephritis and cystitis. And Foley catheter was placed and bladder irrigation was performed. Escherichia coli infection was identified in urine culture and antibiotic was prescribed accordingly. Gas disappeared completely and the patient recovered uneventfully.

CONCLUSION

This is the first case report of asymptomatic EPN and EC in uremic patient, and conservative management was optimistic in this condition. More attention should be paid to EPN and EC happening to ESRD patients.

Complicated bilateral fungal emphysematous pyelonephritis in a 55-year-old diabetic female: A case report and review of literature

Background and Purpose:

Emphysematous pyelonephritis (EPN) is a rare and serious disease causing acute renal failure. Diabetes is a major risk factor for this infection.

Case report:

Herein, we present the case of a 55-year-old female patient with diabetes and EPN caused by Candida albicans. The infection was complicated with endophthalmitis and endocarditis. The results of antifungal susceptibility analysis showed that C. albicans was resistant to fluconazole and susceptible to amphotericin-B and itraconazole. Infection could be controlled by amphotericin-B followed by itraconazole therapy, and the patient was discharged in good condition while receiving antifungal therapy.

Conclusion:

Complicated pyelonephritis with unusual microorganisms should be considered in patients with diabetes and urinary symptoms.

Emphysematous pyelonephritis: Case report and literature overview

INTRODUCTION

Emphysematous pyelonephritis is a rare necrotizing infection of the kidney with a poor prognosis. If it occurs in patients with a reduced general condition, this infection is life threatening. Early diagnosis is made by computed tomography. Treatment options are drainage and intensive care or immediate nephrectomy in severe cases.

CASE DESCRIPTION

A 73-year-old woman in a poor general condition presented with a fulminant urosepsis. Computed tomography revealed an impressive abscess formation of the right kidney with free air retro and intraperitoneal. The diagnosis of emphysematous pyelonephritis was made. Besides septicemia, she had a multiorgan failure including kidney and liver function deterioration. Nephrectomy was performed immediately. The postoperative course was successful with a complete stabilization of the kidney and liver function and reconvalescence of the patient.

DISCUSSION

The widespread availability of imaging techniques leads to early diagnosis and a reduction of mortality of renal and periphrenic abscesses and even of emphysematous pyelonephritis. However, severe cases have a poor outcome and require aggressive and immediate therapy. Besides systemic antibiotic therapy and percutaneous and surgical drainage, radical nephrectomy is a viable therapy option and should be performed immediately in patients with several risk factors, poor prognosis, and extensive findings.

CONCLUSION

Radical nephrectomy being performed immediately seems to be the optimal management in patients with acute emphysematous nephritis and urosepsis.

Septic Pulmonary Emboli or Pulmonary Metastasis in a Patient with Diabetes Mellitus?

Emphysematous pyelonephritis is a rare but life-threatening infection characterized by an accumulation of gas in the renal parenchyma. A high mortality rate was reported, and timely administration of broad-spectrum antibiotics for enteric gram-negative bacilli, such as Escherichia coli, Enterobacter, and Klebsiella pneumoniae, was recommended for improving the clinical outcome. Computed tomography is a useful tool for identifying gas accumulation within the perirenal space. Abdominal ultrasound and abdominal plain film are alternative options with lower accuracy rates. Here, we present the case of a 49-year-old male patient who presented with acute-onset progressive abdominal cramping pain and dysuria. Diffuse bilateral opacities over the lung field and a heterogeneous mass with air density in the abdomen were found on radiological examination. Multiple septic pulmonary emboli and emphysematous pyelonephritis were diagnosed using computed tomography. After emergency percutaneous nephrostomy and administration of broad-spectrum antibiotics, the patient was discharged in a stable condition and followed up at the outpatient department. This report also describes the clinical and imaging features of emphysematous pyelonephritis and highlights that early diagnosis and timely administration of broad-spectrum antibiotics may help avoid a potentially devastating outcome.

Bilateral emphysematous pyelonephritis cured by antibiotics alone in a black African woman

A 78-year-old black woman with a 10-year history of diabetes mellitus was admitted to the intensive care unit. Upon admission, she presented with chills, nausea, and left flank pain. The presence of hyperglycemia (fasting blood glucose, 19.7 mmol/L) and an altered consciousness required immediate treatment with insulin analog. Laboratory investigations and enhanced computed tomography scan led to the diagnosis of bilateral emphysematous pyelonephritis (EPN). The patient responded well to conservative treatment with antibiotics, and was finally discharged after 22 days when the computed tomography scan showed resolution of all the pockets of air. This case and associated literature review of 25 previously reported cases of bilateral EPN show the changing trend of EPN management from emergency nephrectomy toward conservative treatment with potent antibiotics and/or percutaneous drainage, and has been associated with higher survival rates compared to emergency nephrectomy.

Norepinephrine augmented in vitro growth of uropathogenic E. coli in Type 2 diabetes mellitus and its suppression by silodosin (alpha blocker)

Norepinephrine is secreted under conditions of stress in humans. The ability of bacteria to sense mammalian hormone may have a role in propagation of infection. The present study investigated the effect of norepinephrine on in vitro growth of uropathogenic E. coli (UPEC) and the effect of silodosin on norepinephrine-induced changes. The spot urine samples were collected from 56 individuals (14 diabetic patients with UTI, 14 diabetic without UTI, 14 non-diabetic UTI and 14 healthy volunteer controls) for the measurement of urinary norepinephrine concentrations. The concentration of norepinephrine, as found in urine of human subjects, was reproduced in artificial urine medium to study the growth of UPEC. The norepinephrine concentration showing maximum growth response was selected to study the effect of silodosin on the growth inhibition of UPEC. Result showed significantly elevated urinary norepinephrine in diabetic patients with and without UTI and also in nondiabetic UTI groups. The norepinephrine concentration equivalent to that in diabetic UTI patients enhanced the growth of UPEC. Furthermore, silodosin (0.32 μM) inhibited the growth of the UPEC.

Clinical profile and successful outcomes of conservative and minimally invasive treatment of emphysematous pyelonephritis

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a rare clinical entity, characterized by gas in the renal system, due to an acute, fulminant and potentially fatal necrotizing process with varying clinical presentations. It is much more aggressive than uncomplicated pyelonephritis, with the mortality of 20-40% in the contemporary meta-analysis.

MATERIAL AND METHODS

A retrospective record review of inpatients at the Institute of Nephro Urology, Bangalore, India (2007-2014), who were treated after EPN was diagnosed with the aid of a CT (computed tomography) scan.

RESULTS

Sixty-six patients (M:F 27:39) treated for EPN over the past seven years with the mean (±SD) age of 52.32 (±12.48) years were analyzed. Median (interquartile range) duration of hospital stay was 8 (11.25) days with 4 (6%) patients requiring intensive care unit admission (median, IQR = 5.5, 1.5 days) of whom two passed away due to septicemia. Fifty-six (84.85%) patients were diabetics, forty (60.6%) patients had estimated glomerular filtration rate (eGFR) <60 ml/min/1.7 3 m2, 6 (9.1%) patients had eGFR <30 ml/min/1.73 m2 including 3 (4.5%) with eGFR <15 ml/min/1.73 m2 requiring hemodialysis and twenty-two (33%) had thrombocytopenia. Fifty (75.76%) patients were classified as Huang and Tseng Class 2, 7 (10%) as Class 3 with perinephric abscess requiring open drainage and 9 (13.64%) had bilateral EPN (Class 4). Majority (43; 65%) responded to piperacillin-tazobactam treatment. Double J stenting was done in 17 (25.76%) patients, percutaneous drainage in 5 (7.58%) patients and nephrectomy in 2 (3%) patients.

CONCLUSIONS

Although EPN historically carries high morbidity and mortality, modern day medical management with timely intervention in the form of urinary drainage is effective and curative in most patients resulting in a low mortality rate.

Necrotizing Fasciitis of Thoracic and Abdominal Wall with Emphysematous Pyelonephritis and Retroperitoneal Abscess

Emphysematous pyelonephritis is a life-threatening severe form of pyelonephritis usually occurring in patients with diabetes mellitus with or without obstructive uropathies in whom there is necrotizing infection leading to the gas production of an unclear mechanism involving the renal parenchyma and the collecting system. Necrotizing fasciitis is characterized by progressive necrosis of fat and fascia due to deep-seated infection of subcutaneous tissue. It has a fulminant course with considerable mortality. Diabetes Mellitus is a common predisposing factor. The combined occurrence of emphysematous pyelonephritis and necrotizing fasciitis is extremely unusual. Early recognition and management is mandatory to avoid mortality. We report a case of a 53-year-old female, a known case of Type II diabetes mellitus, who presented with necrotizing fasciitis of thoracic and abdominal wall with emphysematous pyelonephritis in the left kidney with a retroperitoneal abscess.

Emphysematous pyelonephritis

Emphysematous pyelonephritis is a gas‐producing, necrotizing infection involving the renal parenchyma and surrounding tissue that is associated with high mortality and morbidity. Common causative organisms include Escherichia coli and Klebsiella pneumoniae. While most patients are being managed conservatively these days, nephrectomy may be needed in severe cases.

Pictorial review: Renal ultrasound

Ultrasound (US) is the first-line imaging modality for evaluating azotemic patients for urinary obstruction and renal size. US is also valuable for distinguishing congenital variants and simple cystic lesions from renal masses. Doppler US is effective in detection of renal calculi and evaluation of vascular pathology. Unfortunately, renal US is limited in distinguishing causes of medical renal disease. The kidneys have a complex internal architecture with a highly variable appearance on US. This article illustrates non-neoplastic renal conditions, including normal and embryological variants, parenchymal, cystic, and vascular diseases. Renal infections, calcifications, and trauma and fluid collections are also discussed, with an emphasis on distinguishing US features and pathophysiology.

A prospective analysis of emphysematous pyelonephritis at a tertiary care centre

Purpose:

To evaluate the presentation and diagnostic criteria of emphysematous pyelonephritis and different modalities of their management at our instititute.

Methods:

A prospective study of 5 years in which patients who were diagnosed to have emphysematous pyelonephritis confirmed by a non contrast CT presenting at our centre were included in this study and baseline information, a brief clinical history with a written consent was collected from each patient. The course of the patient along with investigations and interventions done from admission were recorded.

Results:

72 patients were included in this study with a mean age of 55.4 +/-12.1 years (30 to 75 years ), comprising of 47 females and 25 males. Common presentation was tachycardia (94.5 %) and fever associated with burning micturition (75.3%) followed by loin pain on the affected side (71%). 31 cases which formed a majority were diagnosed to have right sided emphysematous pyelonephritis (41.9%), 28 had left sided (38.35%) and 14 bilateral (19.17%) in our series. 90.41 % of the patient were diagnosed to have diabetes mellitus of which 34 patients (46.57 %) presented with high sugars. Urine cultures were positive in only 41% of the patients with the most common organism being E. coli (68%) followed by Klebsiella pneumoniae (14%). 64.8% of the patients diagnosed were treated conservatively with IV antibiotics and 34.24% by endoscopic management.

Conclusions:

In this study we have shown that a medical line of management with appropriate endoscopic intervention is the present choice of management of emphysematous pyelonephritis irrespective of the CT grade of the disease. Level of evidence: Not applicable for this multicentre audit.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

Emphysematous Pyelonephritis Case Series From South India

Introduction

Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of the kidney. The mortality rate for EPN is as high as 25%. We conducted a retrospective study at MS Ramaiah Hospital between January 2011 and May 2016 to observe the clinical, biochemical, and microbiological patterns of EPN at our institute.

Methods

The clinical and laboratory data, imaging findings, and microbiological patterns of 51 patients chosen for the study were recorded. The data were analyzed to identify the prognostic variables that could predict the morbidity and mortality of patients with EPN, and the focus of this study was to determine risk factors for and outcomes of patients who presented with EPN and who required hemodialysis. Primary endpoints were successful treatment and all-cause mortality. Secondary endpoints included need for hemodialysis and the need for a specific treatment.

Results

There was an equal incidence among both sexes (median age: 59 years). Common symptoms were abdominal pain (94.11%), fever (83.2%), dysuria (74.5%), vomiting (72.54%), frequency of micturition (68.62%), oliguria, generalized weakness (66.67%), and breathlessness (66.67%); 98.03% (n = 50) of the patients had diabetes. The most common organism cultured was Escherichia coli (37.2%). Nineteen patients (37.2%) required dialysis; their mean age was 60.25 ± 11.74 years. Male sex, diabetes mellitus, shock, high serum creatinine at presentation, and uremic symptoms showed no statistically significant association. Indefinite hemodialysis was required by 12.5% of patients. The antibiotic-treated group had a 100% success rate, whereas the Double J (DJ) stenting group (Double J stent, Biorad, India) had 96.42% success rate.

Conclusion

Early diagnosis and broad spectrum antibiotics, together with an appropriately timed intervention, resulted in decreased mortality. Pain in the abdomen and renal angle tenderness were the most common clinical finding. E coli was the most found organism, and early use of broad spectrum antibiotics decreased mortality.