Pyélonéphrite emphysémateuse : diagnostic et traitement

Emphysematous pyelonephritis: Six case reports and review of literature

BACKGROUND

Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection of the renal parenchyma and surrounding tissues that causes the presence of gas in the renal parenchyma, collecting system, or perinephric tissue and has a poor prognosis. EPN occurs primarily in people with diabetes mellitus (DM), but can occur in those without DM when the associated renoureteral unit is obstructed.

CASE SUMMARY

We describe our experience with six patients who developed EPN. Five patients had DM, including one with diabetic ketoacidosis, one with multisystem involvements, including eye, lung and brain. Bilateral urolithiasis was present in one case, along with emphysematous cystitis. Unilateral kidney stones were present in one patient. One patient was an older man in poor general health. Five individuals survived and underwent surgical procedures including ureteral stent installation (Double J stent placement), percutaneous nephrostomy and perinephric abscess puncture drainage, while one died because the patient’s family chose to terminate therapy. Klebsiella pneumoniae and Escherichia coli were the microorganisms implicated.

CONCLUSION

We conclude that EPN is a potentially fatal illness. A positive outcome necessitates early detection. Therapeutic measures should be implemented as soon as a diagnosis is made.

A rare case of double kidney stones and Emphysematous Pyelonephritis presenting with septic shock

Kidney stones and Emphysematous Pyelonephritis with septic shocks is a critical and urgent occurrence has a high mortality rate, which needs to be paid great attention to. Early anti-infection and removal of obstruction play a key role in the treatment.This case report reviews the diagnosis and treatment of the case, discusses the disease characteristics of the disease, and shares our successful clinical experience in treating the disease.

[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.

[Emphysematous cystitis: Report of one case]

INTRODUCTION

Emphysematous cystitis is a rare urinary tract infection characterized by gas in the bladder wall and lumen.

CASE REPORT

We report a 92-year-old women admitted with confusion and abdominal pain without fever. Her past medical history included diabetes, urinary incontinence, high blood pressure and mild cognitive impairment. A computed tomography scan (CT scan) revealed emphysematous cystitis. The patient completely recovered within ten days. The main characteristics and the treatment of this uncommon disorder are presented.

CONCLUSION

Clinicians should be aware of this diagnosis: early management is essential to reduce morbidity and mortality.

[Conservative treatment in diabetic patients with emphysematous pyelonephritis: about five cases]

Acute emphysematous pyelonephritis (EPN) is a severe kidney infection. Early and effective treatment is essential to reduce high mortality rates due to this disease. Our study aims to highlight the clinical and paraclinical features as well as the peculiarities of therapeutic management of this disease and focus on the possibility of conservative treatment in diabetic patients. We analyzed the medical records of patients with EPN treated in the Department of Urology at the Hassan II University Hospital, Fez between January 2004 and January 2010. For each medical record we described clinical, paraclinical and therapeutic features as well as patient's evolution after treatment. We here report the case of 5 female patients whose average age was 45,6 years. All patients were diabetic. Lithiasic obstruction of the upper urinary tract was found in 3 patients (60%). The diagnosis was made by means of abdominal CT scan. All patients underwent resuscitation measures including antibiotic and insulin therapy. Conservative surgical procedure was performed in all cases. Indeed, surgical drainage of perirenal collections was performed in two cases, percutaneous renal drainage in one case and drainage using double-J ureteral catheter in 2 cases. Clinical and radiological evolution was excellent with renal preservation in all patients Emphysematous pyelonephritis is a rare and serious complication, especially in diabetic patients. Diagnosis is based on CT scan. Surgical treatment should be conservative in most cases, apart from severe forms, especially in diabetic patients who have potential risk of chronic renal failure.

[Bilateral emphysematous pyelonephritis caused by Candida glabrata: An exceptional entity]

Acute emphysematous pyelonephritis (AEP) is a severe form of urinary tract infection. It occurs usually in diabetics. The most concerned agents are the Gram-negative bacilli. We report a first case of bilateral AEP due to Candida glabrata, occurred in a 64-year-old diabetic woman. The clinical presentation started with fever and abdominal pains, without signs of urinary tract infection. Within six hours, the patient had developed a septic shock with renal failure and ketoacidosis. The diagnosis was confirmed by CT scan and the pathogen was isolated in urine. Despite antibiotic and antifungal treatment, she died from a septic shock. Acute emphysematous pyelonephritis due to Candida species is rare. However, the addition of antifungal therapy seems justified if a severe emphysematous pyelonephritis is associated with risk factors of Candida infection.

[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.

[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.

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.

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.

Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series)

BACKGROUND

Emphysematous urinary tract infections are rare conditions, usually occurring in diabetic patients. Mortality rates in medically managed patients are reported to be as high as 70% to 90%. Growth of the diabetic population warrants heightened attention to these potentially fatal infections. We report a series of 5 cases with favorable outcomes.

CASE REPORTS

All patients were diabetic. Presenting symptoms included fever, chills, nausea, vomiting, and abdominal pain. On physical examination, two patients had costovertebral angle tenderness; a third was dehydrated; a fourth had dehydration and an abdominal mass; and a fifth patient had suprapubic tenderness. All cases had leukocytosis and impaired renal function. Computed tomography (CT) scan disclosed emphysematous pyelonephritis in 3 cases (gas within renal parenchyma and/or perirenal tissue), emphysematous pyelitis in 1 case (gas in collecting system), and emphysematous cystitis in 1 patient (gas within bladder wall). Urine culture of 1 case grew Enterococci, whereas in the other cases cultures yielded gas-producing organisms. All patients received intravenous antibiotics. Two patients underwent CT-guided abscess drainage; 2 cases had J-stent placement, and one patient was readmitted with septic shock and underwent nephrectomy. All the patients' conditions improved and they were discharged.

DISCUSSION

Emphysematous urinary tract infections are usually caused by gas-producing organisms. They should be suspected in diabetic patients with urinary tract infections and worsening of renal function. CT scan is the method of choice for diagnosis and follow up. None of our patients died, mainly due to early diagnosis, sequential radiologic assessment, and timely surgical intervention when needed.

[Bilateral emphysematous pyelonephritis cured by medical therapy alone]

Emphysematous pyelonephritis is a necrotizing renal infection characterized by bacterial gas production in the renal and perirenal area. It is a rare infection diagnosed in diabetic patients in most cases. Emphysematous pyelonephritis has a high mortality rate. We herein report one case of bilateral emphysematous pyelonephritis managed by medical therapy alone.