Successful management of bilateral emphysematous pyelonephritis with abscess formation in a chronic hemodialysis patient: a case report

Hung up with a Huang class 4: our experience with bilateral emphysematous pyelonephritis in a COVID 19 patient

The COVID 19 pandemic has forced us to rethink our management strategies for surgical diseases. Patients with COVID 19 have increased risk of morbidity and mortality after surgical intervention. Emphysematous pyelonephritis (EPN) is often seen in diabetics and can be a life threatening condition. All patients require immediate treatment with antibiotics and close monitoring. Bilateral EPN is a rare entity seen in less than 10% of patients. We present a case of bilateral EPN in a COVID positive patient which was successfully managed conservatively. A 70 year old hypertensive female, presented to us with fever, breathlessness, loss of appetite, generalised weakness requiring oxygen supplementation & was diagnosed with COVID 19. Bilateral EPN (Grade 4) with perinephric collections was found on evaluation for acute kidney injury. She underwent bilateral pig tail insertion followed by bilateral DJ stenting after stabilization. She recovered dramatically, blood parameters improved and was discharged. At 1 year of follow up, patient was doing well. In the present COVID-19 pandemic where case selection for surgical intervention is crucial, we would like to highlight how a conservative approach for even Class 4 EPN is feasible after weighing the risks and benefits of the same. Patients can be spared the immediate morbidity and mortality risks due to surgical intervention during COVID 19 infection. Triaging surgical intervention can also help in better utilization of critical care facilities and man power, both invaluable in the ongoing crisis.

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.

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.