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

Culture-negative bilateral emphysematous pyelonephritis presented as acute renal failure and managed medically only

Emphysematous pyelonephritis is a life-threatening infection especially seen in patients with poorly-controlled diabetes mellitus. Imaging modalities (preferably computed tomography) are required to establish the diagnosis. Treatment modalities include volume resuscitation, broad-spectrum antibiotics, percutaneous drainage, and, as a last resort, nephrectomy. We present a case of a 46-year-old female who had hypertension and type-2 diabetes mellitus and presented with complaints of dysuria, back pain, and decreased urine output. Renal ultrasound and abdominal computerized tomography (CT) revealed air-fluid levels at each perirenal region and collecting systems, consistent with emphysematous pyelonephritis. Her clinical situation improved with vigorous fluid resuscitation and broad-spectrum antibiotic treatment.

Current management of emphysematous pyelonephritis

Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection that is characterized by the production of intraparenchymal gas. EPN predominantly affects female diabetics, and can occur in insulin-dependent and non-insulin-dependent patients in the absence of ureteric obstruction. Nondiabetic patients can also develop EPN, but often have ureteric obstruction and do not seem to develop such extensive disease. One gaseous component-carbon dioxide-is generated by bacterial fermentation of glucose (present in excess in diabetics) and acids. Patients with EPN show relatively vague symptoms initially, but frequently undergo a sudden deterioration in their condition, necessitating urgent medical attention. Treatment of patients with EPN comprises resuscitation, correction of any electrolyte and glucose problems, and administration of antibiotics targeting Gram-negative bacteria. Ureteric obstruction, if present, is relieved by a percutaneous nephrostomy or stent. Definitive management is by percutaneous drainage, except when there is extensive diffuse gas with renal destruction; in this case, a nephrectomy is advised. The requirement for a nephrectomy could potentially be avoided by early diagnosis and treatment of diabetics with urinary infection. With the advent of CT, a staging system of the gas patterns generated in the kidneys of EPN patients has evolved. Risk factors have been defined to aid management.

Emphysematous pyelonephritis: a case report series of four patients with review of literature

Emphysematous pyelonephritis (EPN) is an acute necrotizing infection with gas presence in the kidney, perinephric space, and/or urinary collecting system that carries a bad prognosis. Some clinical conditions predispose to this entity, such as diabetes mellitus, urinary tract obstruction, and immune-incompetence. Immediate resuscitation, broad-spectrum antibiotics, percutaneous and surgical drainage, and emergent and delayed nephrectomy are therapeutic options that should be applied in a timely fashion. We report our experience of four patients with EPN. Two of the patients were kidney transplant recipients, one patient had bilateral urolithiasis, and one patient was an elderly patient with debilitated general condition and an abdominal mass that could not be defined. Late transplant nephrectomy was performed in one patient, and three patients were treated conservatively. Three patients died, including the patient who had transplant nephrectomy. One patient who presented with lithiasis showed a remarkable recovery with conservative management. The bacteria involved were E. Coli and a resistant Klebsiella. We conclude that EPN is a life-threatening condition that carries a bad prognosis. Early diagnosis is essential for a positive outcome. Therapeutic measures should be applied immediately after diagnosis. An aggressive approach including nephrectomy may be emergently required.

Fulminant emphysematous pyelonephritis (EPN) in a diabetic patient suspected of having multiple tumors

Multiple tumors in the liver, kidney, and on the posterior side of the urinary bladder were accidentally found when a diabetic woman visited the hospital. She refused to undergo surgery; therefore, she was only observed for 2 months. Subsequently, she was found unconscious at home and diagnosed with urinary infection, sepsis, and hyperglycemic hyperosmolar non-ketotic coma. The case followed a fulminant course, and she soon died. Postmortem computed tomography revealed emphysematous pyelonephritis (EPN), a rare, life-threatening infection. This case highlights the importance of carefully managing infection in diabetic patients, and it may contribute to clarifying the pathogenesis of EPN.

A Rare but Potentially Fatal Bacterial Infection in a Patient with Poorly Controlled Diabetes Mellitus: Emphysematous Pyelonephritis

Emphysematous pyelonephritis, a necrotizing infection of the renal parenchyma caused by gas-producing organism, is a rare but life-threatening condition. The initial presentation could be non-specific. We report a case of emphysematous pyelonephritis in a patient presenting with poorly controlled diabetes mellitus and severe sepsis. Its pathogenesis and management are briefly discussed.

Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis

OBJECTIVE

To analyse the factors predicting the mortality and need for nephrectomy in patients with emphysematous pyelonephritis (EPN).

PATIENTS AND METHODS

Clinical features, laboratory variables, imaging studies, management strategy and the final outcomes were analysed in 39 consecutive patients with EPN. The mean (sd) age was 57 (7.2) years and the male to female ratio was 2:11. The baseline risk factors (clinical, laboratory and radiological) were compared among three groups; group 1, survived with renal salvage (26); group 2, survived after nephrectomy (eight); and group 3, died (five).

RESULTS

The overall survival rate was 87% (34/39) and the kidney was salvaged in 67% (26) patients at a median follow-up of 18 months. Altered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation were significantly associated with mortality rate. There was no significant difference in final outcome based on radiological classification. Extensive renal parenchymal destruction of >50% (based on computed tomography) significantly predicted the need for nephrectomy (P < 0.001) and death (P = 0.02). Early (<1 week) nephrectomy resulted in a higher mortality rate (three of seven patients) than initial conservative management. There were no deaths in selected patients who received antibiotics alone or had delayed nephrectomy (four patients each). Of 24 patients who had minimally invasive treatment alone, two (8%) died. Minimally invasive treatment resulted in high renal salvage (22/24, 92%).

CONCLUSION

Altered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation are associated with higher mortality rates, whereas extensive renal parenchymal destruction is associated with a need for nephrectomy. Early nephrectomy is associated with higher mortality rates than is initial conservative management.

Emphysematous pyelonephritis successfully treated by early intervention using a renoureteral catheter

A 49-year-old woman with poorly controlled type 2 diabetes mellitus was admitted to hospital complaining of fever, vomiting, and lower abdominal pain. Laboratory investigation revealed leukocytopenia, high blood sugar, and pyuria. Pyelonephritis was then diagnosed. Escherichia coli was isolated from blood and urinary cultures. In spite of antimicrobial therapy, the patient's condition deteriorated. A computed tomography scan of the abdomen on the second day of hospitalization revealed the presence of air in the collecting system of the left kidney. Emphysematous pyelonephritis was diagnosed, and a renoureteral catheter was promptly inserted via the left ureter into the affected pelvis of the left kidney. Imipenem, cefotiam, and levofloxacin were administered during the clinical course. This early intervention and the appropriate antimicrobial therapy were effective in resolving the infection. Urinary tract infections should be carefully managed in patients with poorly controlled diabetes mellitus.

Diversity and complexity of urinary tract infection in diabetes mellitus

Urinary tract infections (UTIs) are a common burden in patients with diabetes mellitus. Cystitis, ascending infections leading to pyelonephritis, emphysematous complications and renal and perinephric abscesses are well recognised in this group of patients especially if glycaemic control is poor. Despite the clinical significance of UTI in diabetes, it is inadequately understood and management regimens are mostly not evidence based. Anticipation of potential complications and earlier interventions are vital to reduce serious adverse outcomes. Herein we discuss the aetiology, pathogenesis and management of UTI and its local and more remote complications.

Successful treatment of bilateral emphysematous pyelonephritis in a uremic patient without nephrectomy

Emphysematous pyelonephritis (EPN) is a severe and complicated renal infection characterized by gas formation within the infected kidney and its surrounding tissues. Early diagnosis with a high index of suspicion and aggressive treatment are important for improving outcome. Bilateral involvement is rare, and surgical intervention is usually required because of its high mortality rate. A literature review found that EPN has rarely been noted in chronic dialysis patients, and those who show bilateral EPN have demonstrated no survival at all until now. Herein, we presented a 51-year-old diabetic uremic woman who developed right emphysematous pyelitis initially and then progressed to bilateral EPN when hospitalized. Percutaneous drainage (PCD) with simultaneous antibiotic therapy successfully eradicated her renal infection. In this study, all reported cases of EPN in chronic dialysis patients were also reviewed.

Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis

AIM

We aimed to study the clinical profile, prognostic factors, and the 6-month outcome of patients with emphysematous pyelonephritis (EPN) METHODS: All patients admitted with a diagnosis of emphysematous pyelonephritis between January 2001 and July 2007 were included.

RESULTS

Overall 19 cases were diagnosed to have emphysematous pyelonephritis. There were 16 females and three males. Fourteen cases had type 2 diabetes mellitus. Fourteen cases had unilateral involvement and five had bilateral involvement. Eleven cases were classified as having class 1 or 2 disease and eight cases had class 3 and 4 disease. E. coli was the most common organism cultured (68.4%). Five cases underwent percutaneous drainage of the collecting system and three cases had nephrectomy of which 10.5% (two with advanced disease) expired. Shock at admission (p = 0.03), serum creatinine >5.0 mg/dl (p = 0.035) and DIC (p = 0.017) were independent poor prognostic factors. There was no difference in the prognosis between patients who had >or=2 or <2 poor prognostic factors (p = 0.16). However, prognosis was not related to disease class, unilateral vs. bilateral involvement, sepsis or the age of the patient. At 6 months, two patients were on maintenance hemodialysis.

CONCLUSIONS

In cases of EPN, shock, serum creatinine >5.0 mg/dl and DIC at admission are poor prognostic factors. Larger prospective studies are needed to confirm our findings.

Emphysematous pyelonephritis presenting as necrotizing fasciitis of the leg

We report a 50-year-old man with poorly controlled diabetes mellitus who presented with a painful, swollen right leg. He had also experienced right flank pain for 1 week prior to admission. Physical examination was notable for tenderness over the right flank. The right leg was diffusely swollen and exquisitely tender to touch, with palpable crepitance. Laboratory tests revealed leukocytosis and pyuria. Computed tomography showed a right ureteral stone with hydronephrosis and characteristic findings of emphysematous pyelonephritis. Furthermore, a right perirenal gas-forming abscess with extension to the right leg was noted. The patient was successfully treated with antibiotic therapy, aggressive control of blood sugar, percutaneous drainage of the hydronephrosis and perirenal abscess, and aggressive debridement of the leg.

Diabetic ketoacidosis presenting with emphysematous pyelonephritis

Mr. A.M.A. is 28-year-old Egyptian male patient who presented to the ER with diabetic ketoacidosis (DKA) and left loin pain of 3 weeks duration. The patient had a history of hospital admission 5 months earlier because of urinary tract infection and DKA. Workup of this clinical case revealed emphysematous pyelonephritis.

An uncommon cause of postpartum renal failure--bilateral emphysematous pyelonephritis

Peripartum acute renal failure is an important complication related to pregnancy leading to significant morbidity and mortality. Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma, with formation of gas within the collecting system, renal parenchyma, or perirenal tissues. EPN is common in persons with diabetes or urinary tract obstruction. Herein we report a case of bilateral emphysematous pyelonephritis in a postpartum lady who had no evidence of diabetes or urinary tract obstruction. Management of this condition has traditionally been aggressive, and surgery has been considered mandatory. Our patient was managed successfully with antibiotics and supportive measures alone.

Pneumomediastinum as first manifestation of emphysematous pyelonephritis in a patient who is non-diabetic

Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney, characterised by production of gas within the renal parenchyma, collecting system or perirenal tissue. It has a high mortality rate (70% to 90%), and the majority of patients have diabetes mellitus. The left kidney is most common involved and Escherichia coli is the most common pathogen. EPN complicated with pneumomediastinum (PM) has been reported in only four cases previously. Here, a case of PM as first manifestation of EPN in a non-diabetic 81-year-old man is reported. He had experienced back pain and abdominal fullness for 1 week. A plain radiograph, CT aortography and MRI confirmed the diagnosis of EPN complicated with PM. The patient died on the 22nd day of treatment with antibiotics of cefmetazole, gentamycin and metronidazole.

A rare association of emphysematous pyelonephritis with unrecognized diabetes and polycystic kidney

Emphysematous pyelonephritis (EPN) is a rare, severe, gas-forming infection for which the treatment of choice is often an immediate nephrectomy, although many reports exist of conservative treatment of cases with antibiotic therapy and percutaneous drainage of abscesses. It usually occurs in diabetic patients and less frequently in subjects with an obstruction of the corresponding renoureteral unit; other predisposing factors are not common. We report here the case of a 51 year-old woman with a rare association of unrecognized diabetes and bilateral polycystic kidney disease who developed monolateral EPN. She had an emergency right nephrectomy and was admitted to Intensive Care Unit (ICU) for septic shock after surgery, requiring intensive resuscitation. The patient was managed with Coupled Plasma Filtration Adsorption (CPFA). Her clinical conditions rapidly improved and the hemofiltration was soon suspended. Urine and blood cultures were positive for the same Escherichia coli, which was susceptible to all tested antibiotics. The patient was transferred to the Nephrology Division and was discharged from the hospital without further dialysis after 34 days. This case report is somewhat unique because of the unusual association between undetected diabetes and polycystic kidney as predisposing factors of a severe infection of the urinary tract.

Reappraisal of the management and outcome of emphysematous pyelonephritis

This study compared the management, prognostic factors and outcomes of patients with emphysematous pyelonephritis (EPN). Twenty-one patients with EPN were studied between September 1996 and August 2005, and were assigned to two groups. Patients in Group 1 received conservative treatment with/without percutaneous catheter drainage (PCD) while patients in Group 2 underwent nephrectomy following medical treatment and PCD. A post hoc analysis of the prognostic factors was performed between survivors and nonsurvivors, and between the survivors in Group 1 and Group 2. There were 14 patients in Group 1, and seven in Group 2. The mortality in Group 1 was 35.7% (5/14) and in Group 2 was 0% (p = 0.12). There were no statistically significant differences in prognostic factors between the two groups, though patients in Group 1 had relatively lower platelet counts (p = 0.07) and Group 2 patients had a higher incidence of dialysis after nephrectomy (p = 0.03). Comparing the survivors and nonsurvivors, patients with comorbid congestive heart failure and patients initially presenting with consciousness disturbances had higher mortalities (p = 0.02 and p < 0.01, respectively). Nonsurvivors also had lower platelet counts (p = 0.06). In conclusion, medical treatment with/without PCD can be used to manage patients with EPN. More agressive drainage is needed in patients with congestive heart failure who initially present with consciousness disturbances or thrombocytopenia.

Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic

Introduction

Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy.

Case presentation

A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later.

Conclusion

EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

Risk factors for treatment failure in renal suppurative infections

There are conflicting results of published studies about prognostic value of various factors in purulent renal infections. The purpose of this study was to identify and quantify potential risk factors for early and late treatment failure in such infections. A retrospective review of 75 renal suppurative infections, at three tertiary Serbian Clinics of Urology, was conducted. We considered numerous potential risk factors in a multivariate analysis. This series was comprised of 49 women and 26 men, with mean age of 56.7 years. There were 38 and 37 patients who experienced successful and unfavorable early treatment outcome, respectively. Overall mortality rate was 9.3%. Comorbidity [odds ratio (OR) = 1.6], complex suppurative pathological findings (OR = 3.6), presence of Pseudomonas spp. (OR = 6.7), multiple bacterial strains (OR = 2.7), and positive culture itself (OR = 3.6) were the predictors of poor early prognosis. A urological intervention and presence of pyonephrosis significantly increased the chance for good initial outcome (OR = 0.32 and 0.37, respectively). In the late treatment failure analysis presence of comorbidities (OR = 5.8) and treatment complications (OR = 7.5) significantly increased chance for fatal outcome. Patients' baseline health status and complexity of suppuration itself were the most important predictors of clinical outcomes. Surgical drainage dominated over antimicrobial therapy.

Emphysematous pyelonephritis, a rare cause of pneumoperitoneum: a case report and review of literature

INTRODUCTION

Emphysematous pyelonephritis is a gas-producing necrotizing bacterial infection that involves the renal parenchyma and perirenal tissue.

CASE PRESENTATION

We report on a case of a 55 year old Caucasian male with no prior medical history presented with left flank pain and malaise. He was diagnosed with emphysematous pyelonephritis, and was successfully treated in our department. The case is presented along with a literature review.

CONCLUSION

Prompt diagnosis and early treatment is crucial because of the high rate of mortality. Therapeutic modalities and prognostic factors regarding emphysematous pyelonephritis remain controversial.

[Emphysematous pyelonephritis of single kidney: review of literature about one case]

INTRODUCTION

Emphysematous pyelonephritis is a rare and severe form of acute pyelonephritis. It is defined as the presence of gas-producing bacteria in the kidney and in peri-nepheretic areas. We report a case of emphysematous pyelonephritis on a single kidney associated with urolithiasis.

OBSERVATION

A 44-year-old woman, with a history of diabetes and chronic renal failure, presented with left renal colic, anuria, fever and worsening of general state. The diagnosis of emphysematous pyelonephritis was confirmed by CT scan. The treatment was based on antibiotheray, adapted to the renal function, insulinotherapy and urine drainage by a double J stent. The evolution was favourable.

DISCUSSION

Emphysematous pyelonephritis is an uncommon infection, generally affecting female diabetic patients. CT scan is mandatory to confirm diagnosis.

CONCLUSION

Even if it is rare, emphysematous pyelonephritis is associated with a high mortality in the absence of a rapid and effective treatment.

Predictors of surgical site infection in dirty urological surgery

OBJECTIVES

Risk factors for surgical site infection (SSI) following urologic dirty operations have not been clearly identified. This study was conducted to describe incidence, potential risk factors and common causative pathogens of the SSI in such operations.

METHODS

Medical records of patients who had undergone simple nephrectomy or lumbotomy for suppurative renal infection at our institutions from 1999 to 2006 were retrospectively evaluated. The following data were retrieved: presence of SSI, demographic data, laboratory findings, comorbidities, microbiological data, type of renal suppuration, type of urological surgery and antibiotic regimen. Risk factors for SSI were evaluated using the multiple logistic regression model.

RESULTS

Sixty-five patients (mean age 55.6 +/- 13.1 years) were eligible for data analysis. In 20 of them (30.8%) a SSI was identified. The most common isolated pathogens were gram-negative bacteria. At univariate logistic regression analysis risk factors significantly associated with SSI included: presence of emphysematous infection, hypoalbuminemia, number of predisposing conditions, emergency operations, isolation of Enterobacteriaceae, positive pus culture. The use of trimethoprim/sulfamethoxazole was associated with a decreased risk for SSI. Multiple logistic model identified only the emergency operations and isolated Enterobacteriaceae as independent predictors of SSI (odds ratio [OR] = 11.1) (95% confidence interval [CI] = 3.0-40.8) and OR = 3.9 (1.0-14.8), respectively.

CONCLUSIONS

Patients with suppurative renal infections are submitted to life-saving emergency surgery. Urological surgeons should keep in mind that this carries a high risk for subsequent SSI. Effective preventive measures in these circumstance cannot be identified. Further research in this area is necessary to clarify this issue.

Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review

PURPOSE

There is no current consensus on what constitutes the ideal management of emphysematous pyelonephritis. We review the current management strategies including the role of nephron preserving percutaneous drainage in the treatment of emphysematous pyelonephritis.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from 1966 to 2006. Abstracts were reviewed including all types of studies from prospective randomized controlled studies to small retrospective series. All relevant English language articles reporting on at least 5 patients were reviewed.

RESULTS

Ten retrospective studies on 210 patients with emphysematous pyelonephritis met the inclusion criteria. There were 167 females and 43 males with a mean age of 57 years (range 24 to 83). Of the patients 96% had diabetes mellitus and 29% had urinary tract obstruction. The diagnostic accuracy of computerized tomography was 100%. Escherichia coli and Klebsiella were the most common causative agents. The mortality from medical management alone was 50%, medical management combined with emergency nephrectomy was 25% and medical management combined with percutaneous drainage was 13.5%. Mortality was significantly less in patients undergoing percutaneous drainage compared to other treatments (Pearson chi-square p <0.001). Of the patients who underwent medical treatment with percutaneous drainage a small number (15) underwent elective nephrectomy and mortality was 6.6% (1 of 15).

CONCLUSIONS

Percutaneous drainage should be part of the initial management strategy for emphysematous pyelonephritis. This strategy is associated with a lower mortality than medical management or emergency nephrectomy. Delayed elective nephrectomy may be required in some patients.

Emphysematous pyelonephritis: outcome of conservative management

OBJECTIVES

To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis.

METHODS

Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics.

RESULTS

Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%.

CONCLUSIONS

A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

[Management of emphysematous pyelonephritis based on a series of 21 cases]

OBJECTIVE

To define the clinical, laboratory and morphological features of emphysematous pyelonephritis, as well as the treatment modalities, with particular emphasis on the need for urgent treatment.

MATERIAL AND METHODS

Between 1987 and 2004, 21 patients were treated for emphysematous pyelonephritis. Epidemiological, clinical, laboratory and radiological data, treatments and clinical outcome were retrospectively collected for all patients.

RESULTS

This series comprised 15 women and six men with a mean age of 54.6 years. All were diabetic. Upper urinary tract obstruction was demonstrated in 47.6% of cases. The left kidney was affected in 14 patients and the right kidney was affected in six patients. Only one patient had bilateral pyelonephritis. The diagnosis was established by CT in every case. All patients received appropriate intensive care. Treatment was purely medical in one case. Emergency nephrectomy was performed in 12 patients, emergency surgical drainage was performed in three patients, percutaneous drainage was performed in two cases and ureteric catheter drainage was performed in three patients. The mortality rate in this series was 23.8%.

CONCLUSION

Emphysematous pyelonephritis is a serious infection. Early diagnosis is essential, particularly in diabetic patients. The positive diagnosis is based on computed tomography and treatment is now increasingly conservative.

Emphysematous pyelonephritis presenting as gastroenteritis

Emphysematous pyelonephritis (EPN) is a serious and often life-threatening condition due to a gas-producing and necrotizing infection involving the renal parenchyma and perirenal tissue. The infection is almost exclusively seen in diabetic patients, and the main feature of its presence is finding gas within the kidney. Patients usually present with fever, chills, flank pain, and dysuria. Laboratory testing usually reveals hyperglycemia, leukocytosis, pyuria, an elevated blood urea nitrogen (BUN) level, and high serum creatinine level. Other, nonspecific symptoms such as abdominal pain, nausea, vomiting, and diarrhea can accompany acute pyelonephritis, as found in the reported case. The appropriate management of such serious infection requires combined medical and surgical treatment. In severe infection, nephrectomy should not be delayed. We report a case of EPN in a diabetic patient who presented with gastrointestinal symptoms. A high index of suspicion, coupled with a good imaging study [preferably computed tomography (CT) scanning] of the abdomen can lead to early diagnosis. Appropriate medical and surgical management have resulted in a successful outcome.

Emphysematous pyelonephritis in dialysis patient after embolization of failed allograft

Emphysematous pyelonephritis is an uncommon acute infection characterized by the presence of gas in the renal parenchyma. Diabetics account for most cases, and the mortality rate is high. We report a case of emphysematous pyelonephritis after therapeutic embolization of a nonfunctioning renal graft in a nondiabetic dialysis patient. Given the increasing popularity of therapeutic embolization to control graft intolerance syndrome associated with rejected kidneys, physicians should be aware of this potentially severe complication. We discuss the differential diagnosis from entities requiring different management strategies, such as postembolization syndrome, persistence of graft intolerance, and the presence of sterile intrarenal.

Scrotal extension of emphysematous pyelonephritis

We report an extensive form of emphysematous pyelonephritis (EPN) in the right kidney extending from the anterior abdominal wall to the scrotum in a patient with renal calculi with obstructive uropathy and describe the progression route of infection from retroperitoneum to scrotum. Such an extensive occurrence of EPN is very rare. The patient succumbed after 48 h despite aggressive treatment.

Infections in Diabetes Mellitus and Hyperglycemia

Infections in diabetes mellitus are relatively more common and serious. Diabetic patients run the risk of acute metabolic decompensation during infections, and conversely patients with metabolic decompensation are at higher risk of certain invasive infections. Tight glycemic control is of paramount importance during acute infected or high stress state. Infections in diabetic patients result in extended hospital stays and additional financial burden. Given the risks of not alleviating the metabolic dysregulation and the benefits of decent glycemic control, it is necessary that besides antimicrobial therapy, equal emphasis be placed on intensified glycemic control.

Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis

PURPOSE

Emphysematous pyelonephritis, an infection most commonly seen in cases of diabetes mellitus, is associated with considerable case fatality. We identified the factors associated with mortality in patients with emphysematous pyelonephritis and estimated the magnitude of the associations.

MATERIALS AND METHODS

PubMed was searched to identify studies reporting on risk factors of mortality in patients with emphysematous pyelonephritis. A meta-analysis of the eligible studies was performed.

RESULTS

Seven study cohorts, representing 175 patients with emphysematous pyelonephritis, were included in the meta-analysis. The overall mortality rate was 25%, ranging from 11% to 42%. Conservative treatment alone (OR 2.85, 95% CI 1.19-6.81), bilateral emphysematous pyelonephritis (OR 5.36, 95% CI 1.41-20.33), type I emphysematous pyelonephritis (OR 2.53, 95% CI 1.13-5.65) and thrombocytopenia (OR 22.68, 95% CI 4.4-116.32) were associated with increased mortality. Systolic blood pressure less than 90 mm Hg, serum creatinine greater than 2.5 mg/dl and disturbance of consciousness were also found to be associated with increased mortality. However, this finding was based on limited data. On the other hand, there was no association between mortality and diabetes mellitus (OR 0.32, 95% CI 0.05-1.99) in patients with emphysematous pyelonephritis.

CONCLUSIONS

The accumulated and analyzed evidence suggests that conservative treatment, type I emphysematous pyelonephritis, bilateral emphysematous pyelonephritis and thrombocytopenia seem to be significant risk factors for mortality in patients with emphysematous pyelonephritis. These data may be taken into consideration when treating patients with this devastating infection.

Emphysematous pyelonephritis

OBJECTIVE

The mortality rate among patients with emphysematous pyelonephritis (EPN) is high and the best therapy has long been debated.

MATERIAL AND METHODS

Between January 1993 and December 2004, 26 patients diagnosed with EPN were treated at our hospital. Historical, demographic and laboratory data were obtained from medical records for analysis.

RESULTS

The mean age of the patients was 58.7+/-12.7 years. All patients had diabetes, and women outnumbered men (23:3). The clinical findings were non-specific. A plain abdominal X-ray was diagnostic in only 9/26 patients (36%), ultrasonography was accurate in 13 (50%) and CT was diagnostic in all cases. Eighteen patients survived, including all five treated with open drainage and three out of four treated with percutaneous drainage (although one of these later required nephrectomy), and eight died. Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome, obesity and smoking were significant predictors of death.

CONCLUSIONS

Early diagnosis by means of CT and CT-guided percutaneous drainage (which is better than ultrasonography-guided drainage) or open drainage, along with antibiotic treatment, may be a reasonable alternative to nephrectomy for this high morbidity condition.

Extensive emphysematous pyelonephritis

We report an unusually severe case of emphysematous pyelonephritis with very extensive kidney necrosis that led to unilateral nephrectomy. We discuss the diagnosis and treatment options in this very rare complication of pyelonephritis almost exclusively encoutered in diabetic patients.

Failure of sonography to visualize a kidney affected by emphysematous pyelonephritis

We describe a diabetic patient who presented with acute renal failure as a result of acute bilateral emphysematous pyelonephritis. Initially, both an abdominal X-ray examination and a renal sonogram were unremarkable. Two days later, however, the previously visualized right kidney could not be demonstrated again by a repeat renal sonogram. A computed tomogram and a repeat abdominal X-ray study confirmed the diagnosis of emphysematous pyelonephritis. To our knowledge this is one of the few described cases of emphysematous pyelonephritis distinguished by a sonogram's inability to visualize a kidney because of interference with imaging by the gas produced by the bacteria that are responsible for the pyelonephritic infection.

Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus

BACKGROUND

Emphysematous renal tract disease (ERTD) is a rare necrotizing infection of the renal parenchyma and urinary tract caused by gas-producing organisms. ERTD deserves special attention because of its life-threatening potential.

OBJECTIVES

To study the clinical features, radiological classification and prognostic factors of ERTD; and to compare the modalities of management and the outcome among the various radiological classes of ERTD.

PATIENTS AND METHODS

Twenty consecutive patients with diabetes and ERTD, seen over last 3 years in a tertiary care institute of north India, were included in the study. All patients were subjected to computerized tomography (CT) after initial diagnosis by ultrasonography. They were classified into 5 classes as previously described. All patients included in the study were conservatively managed with appropriate antibiotics and/or percutaneous drainage or surgery if required.

RESULT

Mean age (+/- SD) of these subjects was 54.4 +/- 20.6 years; duration of diabetes mellitus 8.6 +/- 5.8 years, and duration of symptoms related with ERTD ranged from 3 days to 3 months. Two patients had isolated emphysematous cystitis, 13 patients had emphysematous pyelonephritis (EPN), 3 had both EPN and cystitis, and 1 patient had EPN with cholecystitis, and 1 patient had EPN with pyomyositis. Only 7 (35%) patients had a history of pneumaturia. Escherichia coli was the commonest microorganism. The radiological distribution in 18 (2 had isolated cystitis) patients with EPN was: 2 patients had class 1; 1 had class 2; 2 had class 3A; 11 had class 3B, and 2 had class 4. Of 20 patients 11 (55%) survived. However, those patients who died had severe EPN based on radiological class (6 had class 3B and 1 had class 4). There was no significant difference between the survivor and non-survivor groups with respect to age, gender, duration of diabetes mellitus, duration of symptoms, serum creatinine level, total leukocyte count, hemoglobin, platelet count and culture positivity.

CONCLUSION

Computerized tomographic class 3B or 4 is the most reliable predictor of outcome in patients with ERTD.