Emphysematous pyelonephritis caused by Candida albicans

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

Background and Purpose:

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

Case report:

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

Conclusion:

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

Emphysematous Pyelonephritis

Six patients (all women, mean age 59.8 years) with emphysematous pyelonephritis, a rare, severe inflammation causing renal parenchymal destruction and affecting diabetics more commonly than non-diabetics, are described. Four of the patients were diabetics. All underwent ultrasound examination (US), and five computed tomography (CT) of the kidneys. CT was the most reliable diagnostic method. Differentiation between gas and calcification was difficult at US in three patients. Conventional tomography was performed in two patients and showed intra-renal gas. All six patients recovered; three patients had nephrectomy, one as an emergency procedure and two as an elective procedure after two weeks of antibiotic treatment. Infection was eradicated in the other three patients by percutaneous drainage, electrolyte correction and antibiotics. It was concluded that while conventional abdominal radiography may permit the diagnosis of emphysematous pyelonephritis by demonstrating intra-renal gas, CT is the most reliable diagnostic examination. Emergency nephrectomy may not be necessary in all cases.

Emphysematous pyelonephritis: A 10-year experience with 26 cases

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.

Emphysematous pyelonephritis: Our experience in managing these cases

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a rare acute necrotising infection of renal parenchyma. We discuss clinical details and treatment strategies of 8 patients with EPN followed at our clinic.

METHODS

We retrospectively reviewed the clinical, laboratory, radiological findings and treatment modalities of 8 patients with EPN followed at our urology clinic between 2012 and 2015.

RESULTS

The mean patient age (female: 5; male: 3) was 62 (range: 51-82) years. Based on computed tomographic findings, EPN was classified as class 1 (n = 3), class 2 (n = 3) and class 3a (n = 2). All patients had fever, flank pain, nausea, and vomiting. Five patients had type 2 diabetes mellitus and 3 diabetic patients also had renal stones. Escherichia coli (n = 6), Klebsiella species (n = 1), and Proteus species (n = 1) were grown in urine cultures. All patients had unilateral involvement. Increased white blood cell counts, sedimentation rate, and C-reactive protein levels were detected in all cases. In addition to medical treatment, 2 patients underwent a nephrostomy catheter placement and another 2 patients underwent nephrectomy upon deterioration of her general health state. After achieving clinical stabilization with medical treatment, 1 patient underwent endoscopic ureteral stone treatment. The remaining 3 cases were treated only with antibiotherapy. All patients were discharged with clinical cure.

CONCLUSION

Mortality rates of EPN are gradually decreasing. Preservation of renal reserve is possible due to early diagnosis, appropriate antibiotherapy, and drainage.

[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

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.

[Emphysematous pyelonephritis: report of a case and review of the literature]

Emphysematous pyelonephritis is a necrotizing renal parenquima infection, which is diabetes mellitus related in almost all cases. This is life threatening and has a high mortality rates despite aggressive management. The most important thing in management is a high diagnostic suspicious and also a rapid treatment, which means nephrectomy. We expose a case giving especial importance to clinical and image diagnose as treatment and evolution. We also make a literature review trying to understand this entity and find pathways for its therapeutic management.

Emphysematous pyelitis presenting as an acute abdomen in an end-stage renal disease patient treated with peritoneal dialysis

Emphysematous pyelitis is air in the renal collecting system in patients with urinary tract infections. This entity is uncommon and seen primarily in patients with diabetes mellitus. We report a case of a patient with end-stage renal disease treated with peritoneal dialysis who developed emphysematous pyelitis who presented with signs and symptoms that were more consistent with appendicitis. The spectrum of infections causing air in the urinary tract and the method by which end-stage renal disease patients are treated are discussed. Patients receiving dextrose peritoneal dialysis are at risk for emphysematous pyelonephritis, pyelitis, and cystitis.

[Emphysematous pyelonephritis: report of 3 cases]

Emphysematous pyelonephritis is a rare and life-endangering suppurative infection characterized by the production of gas in the renal parenchyma and perirenal space. It affects mainly patients with diabetes mellitus. Authors report three cases of emphysematous pyelonephritis and insist on the role of radiological investigations in diagnosis. Through an exceptional case of emphysematous pyelonephritis revealed by hematemesis, they remind the progression route of infection from retroperitoneal to mediastinal space. Prognosis of emphysematous pyelonephritis depends on the patient's general health status and rapidity of diagnosis and treatment. Percutaneous drainage is an alternative to major surgery and is particularly indicated in cases of single kidney or in an inoperable patient.

Genitourinary fungal infections: a therapeutic conundrum

Fungi cause 8% of nosocomial infections. This is caused, in part, by the increasing pool of immunocompromised patients. Elderly, transplant and HIV patients, as well as premature infants, have become prime candidates for invasive fungal infections. The widespread use of broad spectrum antibiotics plays a role. Utilisation of appropriate antifungal treatment modalities requires an understanding of the pathogenesis of infection. This is a challenging problem as fungi can cause different clinical manifestations that depend on the type of fungal species and patient response to the infection. Although Candida spp. are the most frequent pathogen, other species such as Aspergillus and Cryptococcus have become major pathogens. Environmental fungi which include Blastomyces, Coccidioides and Histoplasma have become more aggressive in the vulnerable patient. The genitourinary system can be a source or target of disseminated fungal infection. Diagnosis depends on clinical awareness, utilisation of appropriate diagnostic modalities, imaging modalities and a thorough clinical assessment. The treatment of primary (Blastomyces, Coccidioides, Histoplasma) infection generally requires amphotericin B (AmpB). The opportunistic infections (Aspergillus, Cryptococcus and Candida) may respond to the triazoles although AmpB remains the 'gold standard'. Infections caused by Candida spp. represents the greatest challenge to the clinician. The presence of Candida spp. in the urine may indicate colonisation or infection. Untreated, Candida can remain as a 'saprophyte' or develop ascending infection, sepsis or death. The prophylactic use of fluconazole may in itself result in resistant infection, hence the 'conundrum'.

Successful conservative management of emphysematous pyelonephritis, bilateral or in a solitary kidney

Emphysematous pyelonephritis, bilateral or in a solitary kidney, is a life-threatening condition that requires prompt diagnosis and early intervention. Reported mortality is high, despite desperate surgical measures often ending in loss of renal unit, but medical management, possibly combined with percutaneous drainage, is sometimes successful. We report two cases of emphysematous pyelonephritis, one bilateral and one in a solitary kidney, with successful conservative management. Predisposing factors were insulin-dependent diabetes mellitus and micronodular cirrhosis secondary to chronic alcoholism. Prompt sonographic diagnosis determined the success of conservative management. Escherichia coli was identified as causal factor. In the bilateral case the clinical picture improved within 48 h after control of diabetes and broad-spectrum antibiotic treatment. For the affected solitary kidney, percutaneous drainage and ureteric catheterization were required.

Emphysematous pyelonephritis in diabetic patients

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.

Emphysematous pyelonephritis: a case report and review of the literature

Emphysematous pyelonephritis is a rare and life-threatening suppurative infection of renal parenchymal and perirenal tissues, characterized by spontaneous gas production. Although uncommon (76 cases in the literature), it occurs almost exclusively in diabetic patients (87% of the cases). We describe a recent case of a diabetic woman with emphysematous pyelonephritis due to E. coli, successfully managed with unilateral nephrectomy. Symptoms, diagnostic approach and management are discussed and related to the previously reported series.

Bilateral emphysematous pyelonephritis

Emphysematous pyelonephritis is an uncommon and serious infection associated with gas-forming coliform bacteria. Bilateral involvement is rare with only 10 reported cases in the English literature. Prompt and aggressive management is required to salvage these patients. Preservation of renal function using broad-spectrum antibiotics and surgical drainage provide the greatest benefit to these patients. Three new cases are presented with a brief review of the results of management in the reported cases.

Emphysematous pyelonephritis: surgical implications

Emphysematous pyelonephritis in patients with diabetes mellitus is increasingly recognised as a disease requiring urgent and aggressive treatment. We present 3 cases of emphysematous pyelonephritis; 1 patient required percutaneous nephrostomy followed by nephroureterectomy but the other 2 were successfully managed with antibiotics and control of diabetes. Diagnosis was confirmed by sequential imaging techniques which demonstrated an inflammatory renal mass associated with gas and fluid.