Emphysematous pyelonephritis in an infant

A case series of emphysematous pyelonephritis in COVID-positive patients

Emphysematous pyelonephritis (EPN) is a rare infectious disease affecting the renal and perirenal tissues, wherein gas formation occurs in the renal parenchyma, perinephric tissues, or collecting systems. It can be life threatening with mortality rates upto 60%. Here, we report a case series of EPN during the COVID pandemic with COVID test-positive patients who were diagnosed based on clinical signs, symptoms, and CT scans. One patient was conservatively managed, one underwent nephrectomy, and the others were treated with percutaneous drainage and pigtailing. Despite being critically ill, all the patients recovered uneventfully. Owning to the rarity of the lesion and variations in the clinical spectrum, the diagnosis of EPN is challenging. EPN requires early diagnosis and prompt management. The interventional technique depends on the clinical status of the patient and the severity of the lesion. Although the threshold of intervention is low in normal clinical practice, in covid patients, we tried to manage patients conservatively and intervened only when unavoidable.

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.

Emphysematous pyelonephritis in an infant from Sokoto, north-western Nigeria

Introduction

Emphysematous pyelonephritis is a life-threatening necrotising bacterial infection of the kidneys. It is rare among children and can be fatal if not promptly identified and treated.

Case presentation

A 7-month-old male infant presented to the Emergency Paediatric Unit of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, on 12 November 2019 with a 5-day history of fever and vomiting, and a 3-day history of a progressively enlarging, left-side abdominal mass. There was associated excessive crying on micturition, refusal to feed and weight loss. He looked ill and was in respiratory distress, irritable, febrile (38.8 °C), moderately dehydrated and pale. His weight and length were 5.5 kg and 64 cm. He had a tender, firm and ballotable abdominal mass on the left flank measuring 8 cm × 10 cm. His pulse rate was 140 beats/min, blood pressure 60/40 millimetres of mercury and respiratory rate was 65 cycles/min. He had widespread coarse crepitations and normal heart sounds on chest auscultation.

Management and outcome

An initial diagnosis of sepsis was made. Other considerations were nephroblastoma and neuroblastoma. Ceftriaxone and blood transfusion were commenced with subsequent administration of intravenous fluids. Further radiologic investigations revealed emphysematous pyelonephritis. The patient had percutaneous drainage and extended spectrum β-lactamase-producing Escherichia coli (sensitive to meropenem) which was isolated from the aspirate culture after 48 h of incubation. Meropenem could not be commenced because of non-availability and high cost. The patient subsequently deteriorated and died from septic shock.

Conclusion

Emphysematous pyelonephritis has a fulminant course when not diagnosed promptly and treated adequately.

Case Report: Emphysematous Pyelonephritis With a Congenital Giant Ureterocele

A 14-year-old girl noticed malodorous urine and experienced left flank pain. The patient was presented to our hospital with gradually increasing pain. She had no underlying disease but had a history of pain on micturition for several days. Hematologic examination indicated low white blood cell and platelet counts and a high serum lactate level. Computed tomography showed that a part of the parenchyma of the left kidney had poor contrast and was deteriorated, with fluid and gas retention from the perirenal region to the retroperitoneal cavity. A left hydroureter and large ureterocele were observed in the bladder. She was diagnosed with emphysematous pyelonephritis (EPN) with a giant congenital ureterocele. Vasopressors and blood transfusion failed to maintain normal circulatory dynamics, and an open left nephrectomy and transurethral ureterocele fenestration were performed. The excised outer portion of the left kidney was dissolved by the infection and replaced with blood clots and necrotic tissue. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identified the inflammatory, gas-producing bacteria Actinotignum schaalii, Peptoniphilus asaccharolyticus, and Actinomyces odontolyticus. Meropenem was administered for 4 days postoperatively and then de-escalated to sulbactam/ampicillin for another 10 days. The patient was discharged on day 17 of hospitalization, and the postoperative course remained favorable. EPN is extremely rare in pediatric patients, and it is believed that nephrectomy is sometimes necessary if the patient does not have normal circulatory dynamics despite the use of catecholamines.

Emphysematous Pyelonephritis Following Ureterovesical Reimplantation for Congenital Obstructive Megaureter. Pediatric Case Report and Review of the Literature

Introduction: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of the kidney. To date, very few cases of EPN have been described in the pediatric age. The first case of EPN in a toddler occurring after ureterovesical reimplantation for congenital obstructive megaureter is reported with a literature review. Case Report: A 23-month-old male, with a prenatal diagnosis of obstructive megaureter and incomplete duplication of the left urinary tract, was admitted to our Unit where he underwent surgery to treat increased dilatation of the renal pelvis and appearance of an obstructive curve. The latter was revealed at renal scintigraphy, the exam highlighted the radiographic aspect of the cortical renal parenchymal sufferance. At admission preoperative exams were normal, and no recurrent urinary tract infections were documented. Surgical removal of the left stenotic ureteral common tract of the incomplete duplex collecting system was accomplished; ureterovesical reimplantation was performed without ureteral recalibration. No intraoperative complications were recorded. In the immediate postoperative period, urosepsis and the patient's lethargic condition led to life-threatening conditions requiring urgent admission to the intensive care unit. Biochemical analysis showed leukocytosis, anemia, increased C-reactive protein, prolonged prothrombin time, pancytopenia, hyponatremia. Abdominal sonographic evaluation revealed the presence of gas in the left kidney. Unilateral EPN (Class 2) was confirmed by CT- scan. Escherichia coli was cultured from peripheral blood and antimicrobial therapy was started. No additional interventions were required. The child was discharged 14 days postoperatively with normal renal function. Conclusion: EPN is a serious condition that can occur after surgical treatment for urinary tract obstruction. Early detection of air in the kidney should be considered a sign of complicated urinary tract infection. Immediate aggressive resuscitation and antimicrobial therapy are effective and curative with a positive outcome.

Emphysematous infections of the urinary tract - an audit of 20 patients with review of literature

Emphysematous infection of the urinary tract is a rapidly progressive, necrotizing infection which results into collection of gas and subsequent destruction of the tissues. Although very rare among general population, such necrotizing infection is common, particularly among those with compromised immune status. With the rising trend of people afflicted with diabetes mellitus globally, this fulminating infection may pose a serious threat to the medical fraternity. A high index of suspicion and abdominal CT scan usually helps to establish the diagnosis at an early stage and thereby facilitating aggressive antimicrobial therapy and percutaneous drainage where indicated. Although, extirpation of infected renal unit was the treatment of choice earlier, with the advent of modern imaging, endourological procedures and broad spectrum antibiotics, majority of such patients can be treated with minimal morbidity and mortality even with salvaging of the renal units. We present here the outcome of management of 20 cases with varied spectrum of emphysematous infection.

Emphysematous Pyelonephritis in Children

Emphysematous pyelonephritis is a severe necrotizing infection of the kidneys characterized by gas formation within the parenchyma, the collecting system or the perinephric tissue. To our knowledge, there have only been 4 cases of this condition reported in children. We report 2 additional cases in children managed at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.