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Schrader K, Saunders J. Hepatic veins gas bubbles in a case of emphysematous pyelonephritis. SONOGRAPHY 2023. [DOI: 10.1002/sono.12347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Kai‐Wee Schrader
- Department of Medical Imaging Fiona Stanley Hospital Murdoch Western Australia Australia
- Perth Radiological Clinic Perth Western Australia Australia
| | - Jacqualine Saunders
- Department of Medical Imaging Fiona Stanley Hospital Murdoch Western Australia Australia
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Dong X, You S, Zhang H, Wang D, Pan W, Zhang B, Huang S, Li X, Pang J, Ji W. Venous gas caused by emphysematous pyelonephritis: a case report and review of literature. BMC Urol 2022; 22:154. [PMID: 36123660 PMCID: PMC9487055 DOI: 10.1186/s12894-022-01104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emphysematous pyelonephritis (EPN) is a potentially life-threatening disease caused by a gas-producing necrotizing bacterial infection that involves the renal parenchyma, collecting system, and/or perinephric tissue. EPN is often complicated by a previous diagnosis of diabetes mellitus, and venous air bubbles are an uncommon complication of it. We describe a 52-year-old woman who was admitted in coma, with a history of vomiting, and was found to have EPN with air bubbles in the uterine veins. We discuss the presentation, diagnosis, and pathogenesis of this uncommon but clinically significant event, and briefly review other case reports of venous gas or thrombosis caused by EPN. CASE PRESENTATION We report the case of a 52-year-old woman with past history of type 2 diabetes mellitus, presenting with loss of consciousness after vomiting for half a day. Abdominal computed tomography scan revealed unilateral EPN with air bubbles in the uterine veins. The blood, pus, and urine cultures were positive for extended-spectrum beta-lactamase-producing Escherichia coli. The patient's condition improved well after conservative management comprising supportive measures, broad-spectrum antibiotics, percutaneous drainage therapy, and an open operation. CONCLUSIONS Venous air bubbles are rare but fatal complication of EPN. Early diagnosis and treatment are critical to ensure good results.
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Affiliation(s)
- Xue Dong
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Shuzong You
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Huangqi Zhang
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Dongnv Wang
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Wenting Pan
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Binhao Zhang
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Shanqiang Huang
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Xin Li
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Jianxin Pang
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China
| | - Wenbin Ji
- Department of Radiology, Taizhou Hospital, Zhejiang University, Taizhou, 318000, Zhejiang, China.
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Omoleye D, Israr MA, Tazin F, Habib S, Desai S, Go CC, Aranmolate A, Frontela O. Culture-Negative Emphysematous Pyelonephritis as a Complication of Uncontrolled Diabetes Mellitus: A Case Report. Cureus 2022; 14:e27856. [PMID: 36110486 PMCID: PMC9462396 DOI: 10.7759/cureus.27856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection of the renal parenchyma. It is commonly found as a complication of uncontrolled diabetes mellitus (DM). EPN has a terrible prognosis unless promptly identified and treated. In this case study, a 38-year-old man with type 2 diabetes mellitus (T2DM) was admitted due to complaints of excruciating abdominal pain, vomiting, and non-adherent to his insulin medication. The patient was subsequently diagnosed with EPN. For most patients, the current course of treatment includes nephrectomy along with antimicrobial medications. In this case report, however, the patient improved with conservative treatment such as IV fluids, antibiotics, and blood glucose control.
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Zheng H, Gu C, Jiang S, Liu X, Wang X, Wen C. Sonographic findings of hepatic venous gas in association with spontaneous rupture of a Klebsiella pneumoniae liver abscess: a case report. J Int Med Res 2021; 49:300060521997737. [PMID: 33719686 PMCID: PMC7952855 DOI: 10.1177/0300060521997737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hepatic venous gas (HVG) is a very rare ultrasonic finding, and it is defined as abnormal accumulation of gas in the hepatic venous system. Various diseases can cause HVG, and femoral venous catheter is the most common cause. We, herein, present the case of a 79-year-old female patient with HVG that was caused by spontaneous rupture of a Klebsiella pneumoniae liver abscess. This was first found by bedside ultrasonography. On the basis of the blood culture results, imipenem-cilastatin and cefoperazone sulbactam were administered and the effect was acceptable. After 41 days of antibacterial and symptomatic treatment in the hospital, the patient had recovered well and was discharged. All of the previous reports on HVG have been summarized by thoroughly reviewing the previous published work. Overall, this is the first patient with HVG in association with spontaneous rupture of a K. pneumoniae liver abscess, and it might provide insights for future studies regarding the treatment of this disease.
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Affiliation(s)
- Haining Zheng
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Chenxing Gu
- Department of Emergency, Peking University International Hospital, Beijing, China
| | - Suzhen Jiang
- Department of Infection and Liver Diseases, Peking University International Hospital, Beijing, China
| | - Xiaona Liu
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Xiaoqing Wang
- Department of Ultrasound, Peking University International Hospital, Beijing, China
| | - Chaoyang Wen
- Department of Ultrasound, Peking University International Hospital, Beijing, China
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Emphysematous pyelonephritis with gas in inferior vena cava. Urol Case Rep 2020; 33:101390. [PMID: 33102088 PMCID: PMC7574042 DOI: 10.1016/j.eucr.2020.101390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/16/2020] [Accepted: 08/21/2020] [Indexed: 11/24/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a progressive necrotizing infection of the renal parenchyma, collecting system and perinephric tissue. A 36-year female with uncontrolled diabetes, presented with left emphysematous pyelonephritis, with air in the infra-hepatic inferior vena cava (IVC). She was hydrated, treated with intravenous antibiotics, insulin. Percutaneous nephrostomy with Double J stenting was done in modified supine position. Patient was discharged with nephrostomy. Two weeks later, flexible ureterorenoscopy was done and obstructing papillary necrosis removed. Pneumo-vena cava due to emphysematous pyelonephritis is quite rare and careful evaluation is required. Prompt intervention is life saving and obviates the need for nephrectomy.
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Hazarika S, Venkataramanan R, Das T, Venkataramanan A, Deuri S, Lohchab S, Rongpipi T, Agarwala A. Acute Renal Infection in Adult, Part 2: Emphysematous Urinary Tract Infection—What the Radiologist Needs to Know. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2020. [DOI: 10.1055/s-0039-3400338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractRenal 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.
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Affiliation(s)
- Suman Hazarika
- Department of Radiology, Apollo Hospitals, Guwahati, India
| | | | - Tonmoy Das
- Department of Nephrology, Apollo Hospitals, Guwahati, India
| | | | - Sukanya Deuri
- Department of Radiology, Apollo Hospitals, Guwahati, India
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Bilateral emphysematous pyelonephritis cured by antibiotics alone in a black African woman. Radiol Case Rep 2018; 13:848-854. [PMID: 30002786 PMCID: PMC6040232 DOI: 10.1016/j.radcr.2018.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/24/2018] [Accepted: 05/26/2018] [Indexed: 12/27/2022] Open
Abstract
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.
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El Majdoub A, Khallouk A, Farih MH. [Conservative treatment in diabetic patients with emphysematous pyelonephritis: about five cases]. Pan Afr Med J 2017; 25:151. [PMID: 28292113 PMCID: PMC5326026 DOI: 10.11604/pamj.2016.25.151.6976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 10/08/2015] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Aziz El Majdoub
- Service d'Urologie, Centre Hospitalier Universitaire Hassan II, Fès, Maroc
| | - Abdelhak Khallouk
- Service d'Urologie, Centre Hospitalier Universitaire Hassan II, Fès, Maroc
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Ünlüer EE, Şahı N Y, Oyar O, Tan GC, Karagöz A, Turan CN. A rare case of abdominal infection: Emphysematous pyelonephritis without diabetes. Interv Med Appl Sci 2017; 8:29-31. [PMID: 28250980 DOI: 10.1556/1646.8.2016.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Emphysematous pyelonephritis (EP) is a rare form of necrotizing pyelonephritis. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction. Here, we present the case of an EP caused by urinary tract obstruction without diabetes. A 45-year-old woman presented to the emergency department with fever, chills, and abdominal pain. There was no significant past history. Physical examination depicted bilateral lower abdominal and right flank knocking tenderness. Laboratory exams revealed leukocytosis, neutrophilia, a high C-reactive protein level, and pyuria. Abdominal computerized tomography (CT) showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter. After emergent placement of a percutaneous nephrostomy, she was admitted. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis. The patient was discharged 10 days of post-procedure with instructions for follow-up. Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make a timely diagnosis and navigate management.
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Affiliation(s)
- Erden Erol Ünlüer
- Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital , İzmir , Turkey
| | - Yusuf Şahı N
- Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital , İzmir , Turkey
| | - Orhan Oyar
- Radiology Department. İzmir Katip Çelebi University Atatürk Research and Training Hospital , İzmir , Turkey
| | - Gözde Canan Tan
- Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital , İzmir , Turkey
| | - Arıf Karagöz
- Emergency Department, İzmir Karşıyaka State Hospital , İzmir , Turkey
| | - Celaleddı N Turan
- Urology Department, İzmir Katip Çelebi University Atatürk Research and Training Hospital , İzmir , Turkey
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Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA. Emphysematous pyelonephritis: A 10-year experience with 26 cases. Indian J Endocrinol Metab 2016; 20:475-480. [PMID: 27366713 PMCID: PMC4911836 DOI: 10.4103/2230-8210.183475] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Emphysematous pyelonephritis (EPN) is a necrotizing infection which results in gas within the renal parenchyma, collecting system, or perinephric tissue. A majority of cases occur in patients with diabetes mellitus (DM). In EPN, early aggressive medical treatment may avoid nephrectomy. AIMS The aim of this study was to analyze the characteristics of patients with EPN with respect to patient demographics, clinical presentation, diagnostic investigations, microbiological findings, treatment modality and outcome, and the influence of prognostic factors on the outcome. MATERIALS AND METHODS We reviewed the hospital records of 26 patients with EPN for clinical, laboratory, radiological, and microbiological findings, treatments given, and outcome. The severity of EPN was graded as per the Huang classification. We applied the reported prognostic factors to our patients to find out whether these factors correlated with failure of conservative treatment. RESULTS All the study subjects had DM and all but two of them were females. The majority of our patients (61.5%) had extensive EPN (class 3 or 4) and majority (76.9%) had two or more bad prognostic factors. Escherichia coli was the most common causative organism involved in 50% of our cases. Twenty-three (88.5%) of our patients responded to conservative treatment, two required nephrectomy, and one expired on conservative treatment. CONCLUSIONS In this series of patients with EPN, all had DM, nearly all were women, and E. coli was the most frequently isolated pathogen. Nearly a third of our patients had bilateral disease. Despite the presence of two or more bad prognostic factors and extensive EPN (class 3 or 4) in a majority of our patients, conservative treatment afforded a striking success rate of 88.5%. We recommend early aggressive medical treatment and suggest that nephrectomy should be considered only if patients deteriorate or do not improve on conservative treatment.
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Affiliation(s)
- Raiz Ahmad Misgar
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Idrees Mubarik
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arshad Iqbal Wani
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mahroosa Ramzan
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Bashir Ahmad Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Abstract
Hepatic portal venous gas (HPVG) is an uncommon radiological sign and often portends significant underlying abdominal disease. A number of conditions may produce this sign and identifying the underlying etiology is essential for management. The advent of ultrasonography-color Doppler imaging and computerized tomography has led to more frequent recognition of this condition. This article describes the very rare association of HPVG in a patient with emphysematous pyelonephritis.
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Affiliation(s)
- Debraj Sen
- Department of Radiodiagnosis, Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
| | - Arjun S Sandhu
- Department of Urology, Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
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Dutta D, Shivaprasad KS, Kumar M, Biswas D, Ghosh S, Mukhopadhyay P, Mukhopadhyay S, Chowdhury S. Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature. Indian J Endocrinol Metab 2013; 17:S329-S332. [PMID: 24251204 PMCID: PMC3830350 DOI: 10.4103/2230-8210.119631] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a life-threatening condition most commonly observed in diabetes, with nephrectomy believed to be the treatment of choice. However, nephrectomy in EPN is associated with increased risk of complications secondary to associated hemodynamic instability and may result in lifelong hemodialysis in case of bilateral EPN. We present three patients of severe bilateral EPN and one patient of unilateral EPN with diabetic ketoacidosis (DKA) successfully managed conservatively. Patient 1 (severe bilateral EPN) and patient 4 (unilateral EPN with DKA) responded to aggressive broad spectrum antibiotics, whereas patients 2 and 3 (severe bilateral EPN) responded to broad spectrum antibiotics along with percutaneous catheter drainage (PCD). PCD resulted in initial drainage of 300 and 200 ml of pus, respectively. All patients had associated uncontrolled hyperglycemia, poor glycemic control (HbA1c >8.5%), prerenal and intrinsic renal failure, leukocytosis, and dyselectrolytemia which responded to aggressive supportive management and insulin. There are several reports of successful medical management of severe bilateral EPN. Nephrectomy might no longer be the preferred treatment of severe bilateral EPN and may be reserved for patients' refractory to antibiotics and PCD. Urgent randomized controlled trials are warranted in EPN to optimize the treatment protocols.
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Affiliation(s)
- Deep Dutta
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - K. S. Shivaprasad
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Manoj Kumar
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Dibakar Biswas
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Pradip Mukhopadhyay
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
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Kumar S, Neogi S, Gautam KK. Is aggressive therapy the answer for all cases of emphysematous pyelonephritis: a report of three cases. J Surg Tech Case Rep 2013; 4:106-9. [PMID: 23741587 PMCID: PMC3673351 DOI: 10.4103/2006-8808.110268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Emphysematous Pyelonephritis (EPN) is a severe, necrotizing, life threatening infection of the renal parenchyma and management is not standardised due to scarcity of literature. We present 3 patients with this rare entity. All 3 patients were of class III on CECT findings based on Huang's classification and had more than two risk factors. Our first patient underwent percutaneous drainage of his condition upon which he recovered. The second and third patients underwent a laparotomy and nephrectomy. The second patient recovered after a stormy post operative period and the third patient died. Management of the first patient was contrary to that recommended in literature, for the other two it was as per recommendations. On successful management of our first patient without surgery and seeing no discernable benefits of surgery for our other two patients, it is possible that percutaneous drainage alone, coupled with antibiotics may be a viable strategy for managing this condition with nephrectomy being considered as a second tier option.
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Affiliation(s)
- Sidharth Kumar
- Department of General Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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14
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Benelhoul W, Basset T, Salhi MS, Kallel H, Hommel D. [Emphysematous pyelonephritis: a rare complication of upper urinary tract infections]. ACTA ACUST UNITED AC 2012; 31:262-3. [PMID: 22305396 DOI: 10.1016/j.annfar.2011.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 11/22/2011] [Indexed: 11/29/2022]
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Hata K, Hatano T, Uno T, Tsuzuki S, Koike Y, Kishimoto K, Kira S, Kiyota H, Egawa S, Miyake R, Otani K. [Emphysematous pyelonephritis and cystitis concurrence; A case report]. KANSENSHOGAKU ZASSHI. THE JOURNAL OF THE JAPANESE ASSOCIATION FOR INFECTIOUS DISEASES 2011; 85:674-677. [PMID: 22250460 DOI: 10.11150/kansenshogakuzasshi.85.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We report a case of emphysematous pyelonephritis coexisting with emphysematous cystitis. A 57-year-old woman seen for abdominal pain, diarrhea, and high fever had been referred after computed tomography (CT) elsewhere had shown an air density mass in the left kidney and pelvis. Abdominal CT on admission showed emphysematous change in the left renal parenchyma and intramural bladder. Serum analysis results showed disseminated intravascular coagulation (DIC) and uncontrolled diabetes. Klebsiella pneumoniae was isolated in the blood. She was diagnosed with sepsis based on these findings due to concurrent emphysematous pyelonephritis and cystitis caused by K. pneumoniae. She was treated conservatively with meropenem, intravenous immunoglobulin, and gabexate mesilate and cured. Concurrent emphysematous cystitis and pyelonephritis is rare., with ours only the fourth case reported in Japan.
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Affiliation(s)
- Kenichi Hata
- Department of Urology, Jikei University Affiliated Kashiwa Hospital
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Abstract
The author reports the case of a well and fit patient who presented herself to the emergency department and was found to have bilateral emphysematous pyelonephritis. She was admitted to the intensive care where she was initially treated conservatively with antibiotics, percutaneous drainage and continuous renal replacement therapy, but her condition deteriorated. She underwent a left total nephrectomy and a partial right nephrectomy that resulted in remarkable improvement. The patient started passing urine spontaneously, so no haemofiltration was required. She was discharged home and her case was followed-up by an urologist and nephrologist. This case lays emphasis on thoroughly investigating and managing a patient with bilateral emphysematous pyelonephritis and, in relation to its management, on the dilemma of whether the treatment of choice should be conservative or surgical.
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Affiliation(s)
- John Surur
- Department of Acute Medicine/Anaesthetics, Kings College Hospital, Westminster, London, UK.
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Tichauer M, Sakpal SV, Chamberlain RS. Right Ventricular Pneumocardia Secondary to Hepatic Abscesses. Case Rep Gastroenterol 2010; 4:498-501. [PMID: 21103210 PMCID: PMC2988865 DOI: 10.1159/000321158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Gas-filled abscesses and gas gangrenes are extremely rare causes of intrahepatic gas. Even rarer, however, is the occurrence of gas within the non-portal hepatic veins. Most often seen in diabetic patients, dissemination and hepatic seeding of bacteria has been linked to procedures such as femoral catheters as well as liver lacerations and pyelonephritis. We report the case of a 69-year-old relatively healthy male who presented to our emergency department with abdominal pain and a fever of 103.3°F (39.6°C). A contrast-enhanced computed tomography scan of the abdomen revealed multiple hepatic abscesses and gas within the hepatic venous system as well as pneumocardia. In conclusion, gas within the non-portal hepatic veins is usually an indication of a serious underlying condition and its immediate identification is essential for treatment as hematogenous dissemination has already begun.
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Affiliation(s)
- Matthew Tichauer
- Department of Surgery, Saint Barnabas Medical Center, Livingston, N.J., USA
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Watanabe H, Suzuki R, Asano T, Shio K, Iwadate H, Kobayashi H, Matsuoka T, Aikawa K, Ohira H. A case of emphysematous pyelonephritis in a patient with rheumatoid arthritis taking corticosteroid and low-dose methotrexate. Int J Rheum Dis 2010; 13:180-3. [PMID: 20536605 DOI: 10.1111/j.1756-185x.2010.01460.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease that is characterized by chronic synovial inflammation. Patients with RA have increased risk of infection; this is related to RA itself or the adverse effects of medication. In this report, we describe a case of emphysematous pyelonephritis in a patient with RA associated with AA amyloidosis and steroid-induced diabetes mellitus who was taking corticosteroid and low-dose methotrexate.
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Affiliation(s)
- Hiroshi Watanabe
- Department of Gastroenterology and Rheumatology, School of Medicine, Fukushima Medical University, Fukushima, Japan.
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19
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Alcock J, Brainard AH. Gene–environment mismatch in decompression sickness and air embolism. Med Hypotheses 2010; 75:199-203. [DOI: 10.1016/j.mehy.2010.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 02/17/2010] [Indexed: 02/04/2023]
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Abstract
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.
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21
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Middela S, Green E, Montague R. Emphysematous cystitis: radiological diagnosis of complicated urinary tract infection. BMJ Case Rep 2009; 2009:bcr05.2009.1832. [PMID: 22162733 DOI: 10.1136/bcr.05.2009.1832] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Emphysematous cystitis is an uncommon condition characterised by the presence of gas in the bladder. It is an infection caused by gas forming organisms, usually in elderly women with a background of diabetes mellitus. The presentation is variable, however with increasing use of imaging more cases are being diagnosed in asymptomatic patients. Routine cross-sectional imaging is not advocated for specific diagnosis but its role in accurate assessment of the severity of the condition cannot be overlooked. As the mode and duration of follow-up in incidentally detected cases has not been addressed in the literature, follow-up should be tailored individually depending upon the severity and response to treatment. We describe two such incidentally detected cases of emphysematous cystitis in elderly diabetic patients and present a review of the literature. The triad of treatment is adequate control of diabetes, antibiotics and bladder drainage. One patient died in the hospital, while the other underwent a flexible cystoscopy 6 weeks later which was normal.
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Affiliation(s)
- Seshikanth Middela
- University Hospitals of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
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22
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Su CY, Lee LC, Lai CH, Wang YH, Yang YK, Ng HY, Lee WC, Tsai YC, Chuang FR, Lee CT. Successful treatment of bilateral emphysematous pyelonephritis in a uremic patient without nephrectomy. Ren Fail 2009; 31:167-70. [PMID: 19212917 DOI: 10.1080/08860220802595989] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Chien-Yu Su
- Division of Nephrology, Department of Internal Medicine, Chang-Gung Memorial Hospital- Kaohsiung Medical Center, Chang-Gung University College of Medicine, Kaohsiung, Taiwan
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24
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Poley RN, Ho J, Gooding GA. Sonographic findings of systemic and hepatic venous gas associated with hemodialysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:533-536. [PMID: 19321682 DOI: 10.7863/jum.2009.28.4.533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Rainer N Poley
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143-0628, USA.
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25
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[Management of emphysematous pyelonephritis based on a series of 21 cases]. Prog Urol 2008; 18:102-7. [PMID: 18396237 DOI: 10.1016/j.purol.2007.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Accepted: 08/01/2007] [Indexed: 12/18/2022]
Abstract
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.
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Huang JJ, Chen HM, Cheng MF, Sung JM, Tseng CC, Wang MC. Portal Vein Gas in a Diabetic Patient with Gas-forming Pararenal Abscess. Int J Organ Transplant Med 2007. [DOI: 10.1016/s1561-5413(07)60008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
An 86-year-old nondiabetic woman with an episode of transient ischemic attack two days earlier was referred to our hospital. She had a history of neurogenic bladder and chronic atrial fibrillation and had been anuric for two days. Bubbles were detected by echocardiography in the right atrium, right ventricle, and inferior vena cava. Computed tomography revealed gas accumulation in the wall and lumen of the bladder. She recovered after urinary drainage and antibiotic therapy, and bubbles were no longer detected. It was suspected that bacterial injury of the bladder wall and high intravesical pressure led gas to enter the venous system.
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Affiliation(s)
- Eiji Karashima
- Department of Cardiology, National Fukuoka Higashi Medical Center
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Abstract
Emphysematous pyelonephritis is a necrotizing kidney infection characterized by the presence of gas in renal parenchyma, collecting system or perinephric tissue. This rare affection occurs almost exclusively in patients with diabetes mellitus and is due to non-anaerobic gas-producing bacteria. This life-threatening condition leads to septic shock and multiple organ failure. Diagnosis is suspected when a pyelonephritis does not respond to correct treatment, especially with altered vital signs or a diabetic patient. Computed tomography scan permits visualization of the gas and a radiologic classification with a prognostic value. Current treatment modalities are based upon repeated clinical and scanographic evaluations. In addition to systematic antibiotic therapy, percutaneous drainage is probably the first therapeutic stage in the majority of cases, but should not delay emergent rescue nephrectomy if necessary.
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Affiliation(s)
- E Kaiser
- Anesthésiste-réanimateur des Hôpitau des Armées, département d'anesthésie-réanimation, France.
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Lee HL, Lee HC, Guo HR, Ko WC, Chen KW. Clinical significance and mechanism of gas formation of pyogenic liver abscess due to Klebsiella pneumoniae. J Clin Microbiol 2004; 42:2783-5. [PMID: 15184470 PMCID: PMC427832 DOI: 10.1128/jcm.42.6.2783-2785.2004] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We enrolled 22 patients with gas-forming pyogenic liver abscess in a study to assess the mechanism of gas formation. Klebsiella pneumoniae was cultured from specimens from all patients. Gas and pus samples from abscesses revealed four major components: nitrogen, oxygen, carbon dioxide, and hydrogen; this implicates mixed acid fermentation of glucose as the mechanism of gas formation.
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Affiliation(s)
- Hsin-Ling Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Rd., Tainan 704, Taiwan.
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Flores G, Nellen H, Magaña F, Calleja J. Acute bilateral emphysematous pyelonephritis successfully managed by medical therapy alone: a case report and review of the literature. BMC Nephrol 2002; 3:4. [PMID: 12057010 PMCID: PMC116587 DOI: 10.1186/1471-2369-3-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2002] [Accepted: 06/03/2002] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Bilateral emphysematous pyelonephritis is a life threatening condition usually occurring in diabetics. Management of this condition has traditionally been aggressive and surgery is considered mandatory. However, this is itself a hazardous intervention in a septic, unstable patient with circulatory or liver failure. When bilateral disease is present, the need for long-term dialysis is obviously unavoidable. CASE PRESENTATION We herein report one of the few cases of bilateral emphysematous pyelonephritis successfully managed by non-surgical treatment.
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Affiliation(s)
- Guillermo Flores
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Haiko Nellen
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Francisco Magaña
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Juan Calleja
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Tahir H, Thomas G, Sheerin N, Bettington H, Pattison JM, Goldsmith DJ. Successful medical treatment of acute bilateral emphysematous pyelonephritis. Am J Kidney Dis 2000; 36:1267-70. [PMID: 11096052 DOI: 10.1053/ajkd.2000.19844] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Emphysematous pyelonephritis most often presents as an acute medical emergency, typically in a septic diabetic patient with acute renal failure. The management of this condition has traditionally been surgical, with nephrectomy. However, some recent reports have described successful medical interventions. We describe a case of acute bilateral emphysematous pyelonephritis in a frail patient not suitable for bilateral nephrectomy and long-term dialysis. This condition was managed medically, not surgically, with intensive antibiotic and circulatory support. The outcome was complete recovery after months of hospital-based treatment. We discuss the management of this rare but important condition in detail.
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Affiliation(s)
- H Tahir
- Renal Department, Guy's Hospital, London, England
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Haddad H, Bouslama K, Hajri M, Aloulou R, Ben Moualli S, Ayed M, Ben Dridi M. La pyélonéphrite emphysémateuse. À propos de sept observations. Med Mal Infect 2000. [DOI: 10.1016/s0399-077x(00)80004-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Pagnoux C, Cazaala JB, Méjean A, Haas C, Brochen J, Boitard C, Timsit J. [Emphysematous pyelonephritis in diabetics]. Rev Med Interne 1998; 18:888-92. [PMID: 9499990 DOI: 10.1016/s0248-8663(97)81963-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Emphysematous pyelonephritis is a rare, life-threatening complication of upper urinary tract infections, characterized by the presence of gas in renal parenchyma and perirenal space. It occurs in 90% of cases in diabetic patients and E coli is the most common causative germ. The pathogenesis probably involves several factors including enhanced proliferation of microorganisms due to altered immune defences, mixed acid fermentation of glucose leading to gas production, and decreased elimination of the gas because of impaired tissue perfusion. Diagnosis is often delayed because the symptoms may be non-specific, as illustrated by the two cases we report herein. In patients with diabetes and febrile urinary tract infection, obstruction of the urinary tract should first be eliminated by echography. Then, if the infection does not rapidly respond to antimicrobial therapy, a scan should be performed. Aggressive management including correction of hemodynamics, parenteral antimicrobial therapy, and diabetes control with insulin therapy is mandatory, but a surgical procedure (nephrectomy or drainage) is almost always required.
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Affiliation(s)
- C Pagnoux
- Unité de diabétologie, service d'immunologie clinique, hôpital Necker-Enfants-Malades, Paris, France
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Abstract
In any diabetic patient being diagnosed or treated for pyelonephritis, it is important to exclude the diagnosis of emphysematous pyelonephritis, which carries a high mortality rate. The authors present an illustrative case of emphysematous pyelonephritis treated with antibiotics and emergency nephrectomy. The signs, symptoms, pathophysiology, diagnosis, and treatment of emphysematous pyelonephritis are discussed.
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Affiliation(s)
- T P McHugh
- Department of Emergency Medicine, Richland Memorial Hospital, Columbia, SC 29203, USA
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Pontin AR, Barnes RD, Joffe J, Kahn D. Emphysematous pyelonephritis in diabetic patients. BRITISH JOURNAL OF UROLOGY 1995; 75:71-4. [PMID: 7850302 DOI: 10.1111/j.1464-410x.1995.tb07237.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine the clinico-pathological profile of patients with emphysematous pyelonephritis (EPN). PATIENTS AND METHODS The records of 22 diabetic patients who presented with EPN were reviewed. RESULTS EPN occurred predominantly in female diabetic patients without evidence of ureteric obstruction. The ages of the patients and the duration of the diabetes were variable. EPN occurred in insulin-dependent as well as non-insulin-dependent patients. The patients presented following a prodromal illness of urinary sepsis, with an acute severe illness with symptoms and signs on the affected side. Dehydration and ketoacidosis were common. The diagnosis was made by recognizing gas in the kidney on an X-ray or ultrasound. Eighteen patients were subjected to emergency nephrectomy. CONCLUSIONS EPN is an uncommon, life-threatening condition characterized by the production of intraparenchymal gas. We believe that vigorous resuscitation and emergency nephrectomy is the treatment of choice.
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Affiliation(s)
- A R Pontin
- Department of Urology, Groote Schuur Hospital, South Africa
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