Interventional Medicine & Applied Science, Vol. 8 (1), pp. 29–31 (2016)
CASE REPORT
A rare case of abdominal infection: Emphysematous pyelonephritis without diabetes ERDEN EROL ÜNLÜER1,*, YUSUF ŞAHİN1, ORHAN OYAR2, GÖZDE CANAN TAN1, ARİF KARAGÖZ3, CELALEDDİN TURAN4 1
Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey Radiology Department. İzmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey 3 Emergency Department, İzmir Karşıyaka State Hospital, İzmir, Turkey 4 Urology Department, İzmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey *Corresponding author: Erden Erol Ünlüer, MD; Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey; Phone: +90 (232) 244 44 44-2696; Mobile: +90 (533) 5763441; E-mail: [email protected] 2
(Received: November 17 2015; Revised manuscript received: February 1 2016; Accepted: February 2 2016) 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. Keywords: emphysematous pyelonephritis, emergency, urinary obstruction
Introduction
Case report
Emphysematous pyelonephritis (EP) with nephrolithiasis is a rare form of necrotizing pyelonephritis with a variable clinical picture ranging from mild abdominal pain to septic shock. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction [1, 2]. Here, we present the case of a patient presenting with fever, along with flank and abdominal pain, in our emergency department (ED). The patient was diagnosed as having EP with urinary tract obstruction, which is a rare cause of renal infection.
A 45-year-old woman presented to the ED with fever, chills, and abdominal and right flank pain over the previous 2 days. There was no significant past or family history and no previous atopic reactions. Upon arrival, her vital signs were as follows: temperature of 37.7 °C, pulse rate of 88/min, respiratory rate of 24/min, and blood pressure of 90/60 mm Hg. Physical examination showed bilateral lower abdominal and right flank knocking tenderness. Laboratory examinations were as follows: white cell count of 19,800/μL with predominance of neutrophils (87%) and C-reactive protein of
DOI: 10.1556/1646.8.2016.1.6
29
ISSN 2061-1617 © 2016 The Authors
Ünlüer et al.
Fig. 1.
Abdominal computed tomography without contrast of the patient shows diffuse gas in the right renal collecting system and dilatation of right renal pelvis, including the related ureter, compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter (arrows)
Fig. 2.
patients with urinary obstruction account for 20% [6, 9]. The organisms commonly responsible for causing EP are E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, citrobacter, and, rarely, yeast [10, 11]. If left untreated, the condition is uniformly fatal. Acute pyelonephritis is a multifocal infection of one or both kidneys. Patients with uncomplicated pyelonephritis usually exhibit resolution of all symptoms within 72 h of the commencement of appropriate antibiotic therapy. Patients who fail to improve should be imaged to detect complications, and according to the American College of Radiology Appropriateness Criteria, CT is the preferred modality for patients with a clinical presentation of acute pyelonephritis [12]. CT can show the severity of this condition in detail, including unilateral and bilateral involvement, focal or diffuse infection, the presence of focal swelling, and the presence of kidney enlargement and complications (renal or extrarenal abscess, gas production, obstruction). Several classification systems have been proposed to correlate imaging findings with subsequent prognosis and management of patients with EP. The mildest forms are confined to the collecting system or from loculated air-fluid collections in or adjacent to the kidneys. This may be amenable to percutaneous drainage, as occurred in our case. The more severe infections are characterized by the spread of gas into the renal parenchyma and can extend into the perinephric and paranephric spaces, often requiring an emergency nephrectomy [2]. Conventional radiographs may demonstrate a cluster of mottled lucencies within the kidneys. Ultrasonography shows echogenic foci with “dirty” shadowing within the kidneys. On the CT, collections of gas are seen directly as hypoattenuating foci in the renal lodge. There was no consensus on the management of EP based on random-
17.9 mg/dL (reference value: 0.01–0.82 mg/dL). The urine analysis showed pyuria >73.99/high power field. Radiography and ultrasonography of the abdomen by the radiology department revealed no remarkable pathology, and abdominal computed tomography (CT) without contrast was ordered. The abdominal CT showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis, including the related ureter, compared to the right side, in addition to multiple millimetric stones located in the right kidney and the right ureter (Fig. 1). These imaging findings confirmed the diagnosis of EP of the right kidney with nephrolithiasis. After the patient underwent fluid resuscitation and a course of antibiotics with piperacillin–tazobactam for sepsis, in addition to emergent placement of a percutaneous nephrostomy, she was admitted to the urology department. Three days later, the urine culture grew Escherichia coli and her antibiotic was changed to meropenem accordingly. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis (Fig. 2). The patient was discharged from the urology service 10 days post-procedure with instructions for follow-up.
Discussion Kelly and MacCallum [3, 4] first described EP in 1898. It is an acute necrotizing parenchymal and perianal infection caused by gas-forming uropathogens [3, 5, 6]. Predisposing factors include gas-forming bacteria, high tissue glucose, defective immune responses, and impaired tissue perfusion [7]. Diabetic patients account for more than 90%–96% of cases [2, 8], and
ISSN 2061-1617 © 2016 Akadémiai Kiadó, Budapest
Control abdominal computed tomography of the patient after drainage. The gas has disappeared, but hydronephrosis and nephrolithiasis in right kidney remain (arrows)
30
Interventional Medicine & Applied Science
Emphysematous pyelonephritis
ized controlled trials, so treatment decisions mainly depend on the clinical condition of the patients, along with the imaging findings.
2. Huang JJ, Tseng CC: Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 160, 797–805 (2000) 3. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M: Emphysematous pyelonephritis. J Urol 131, 203–208 (1984) 4. Kelly HA, MacCallum WG: Pneumaturia. JAMA 31, 375–381 (1898) 5. Ouellet LM, Brook MP: Emphysematous pyelonephritis: an emergency indication for the plain abdominal radiograph. Ann Emerg Med 17, 722–724 (1988) 6. Evanoff GV, Thompson CS, Foley R, Weinman EJ: Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 83, 149–154 (1987) 7. Chen KW, Huang JJ, Wu MH, Lin XZ, Chen CY, Ruaan MK: Gas in hepatic veins: a rare and critical presentation of emphysematous pyelonephritis. J Urol 151, 125–126 (1994) 8. Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ: Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis 46, 432–439 (2005) 9. Cook DJ, Achong MR, Dobranowski J: Emphysematous pyelonephritis. Complicated urinary tract infection in diabetes. Diabetes Care 12, 229–232 (1989) 10. Andersen JB: Pyelonephritis emphysematosa. En alvorlig komplikation til diabetes mellitus. Ugeskr Laeger 154, 1419–1421 (1992) 11. Wang JM, Lim HK, Pang KK: Emphysematous pyelonephritis. Scand J Urol Nephrol 41, 223–229 (2007) 12. Sandler CM, Amis ES Jr, Bigongiari LR, Bluth EI, Bush WH Jr, Choyke PL, Fritzsche P, Holder L, Newhouse JH, Segal AJ, Resnick MI, Rutsky EA: Imaging in acute pyelonephritis. American College of Radiology. ACR Appropriateness Criteria. Radiology 215, 677–681 (2000)
Conclusions Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make an early diagnosis and to navigate management of the disease. *** Funding sources: No financial support was received for this study. Authors’ contribution: EEÜ and YŞ developed the concept and performed the drafting of the article; AK and GCT performed the preparation and revision of the article; and OO and CT performed the acquisition of data. Conflict of interest: The authors declare no conflicts of interest.
References 1. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T: Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 49, 343–346 (1997)
Interventional Medicine & Applied Science
31
ISSN 2061-1617 © 2016 Akadémiai Kiadó, Budapest
CASE REPORT
A rare case of abdominal infection: Emphysematous pyelonephritis without diabetes ERDEN EROL ÜNLÜER1,*, YUSUF ŞAHİN1, ORHAN OYAR2, GÖZDE CANAN TAN1, ARİF KARAGÖZ3, CELALEDDİN TURAN4 1
Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey Radiology Department. İzmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey 3 Emergency Department, İzmir Karşıyaka State Hospital, İzmir, Turkey 4 Urology Department, İzmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey *Corresponding author: Erden Erol Ünlüer, MD; Emergency Department, Izmir Katip Çelebi University Atatürk Research and Training Hospital, İzmir, Turkey; Phone: +90 (232) 244 44 44-2696; Mobile: +90 (533) 5763441; E-mail: [email protected] 2
(Received: November 17 2015; Revised manuscript received: February 1 2016; Accepted: February 2 2016) 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. Keywords: emphysematous pyelonephritis, emergency, urinary obstruction
Introduction
Case report
Emphysematous pyelonephritis (EP) with nephrolithiasis is a rare form of necrotizing pyelonephritis with a variable clinical picture ranging from mild abdominal pain to septic shock. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction [1, 2]. Here, we present the case of a patient presenting with fever, along with flank and abdominal pain, in our emergency department (ED). The patient was diagnosed as having EP with urinary tract obstruction, which is a rare cause of renal infection.
A 45-year-old woman presented to the ED with fever, chills, and abdominal and right flank pain over the previous 2 days. There was no significant past or family history and no previous atopic reactions. Upon arrival, her vital signs were as follows: temperature of 37.7 °C, pulse rate of 88/min, respiratory rate of 24/min, and blood pressure of 90/60 mm Hg. Physical examination showed bilateral lower abdominal and right flank knocking tenderness. Laboratory examinations were as follows: white cell count of 19,800/μL with predominance of neutrophils (87%) and C-reactive protein of
DOI: 10.1556/1646.8.2016.1.6
29
ISSN 2061-1617 © 2016 The Authors
Ünlüer et al.
Fig. 1.
Abdominal computed tomography without contrast of the patient shows diffuse gas in the right renal collecting system and dilatation of right renal pelvis, including the related ureter, compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter (arrows)
Fig. 2.
patients with urinary obstruction account for 20% [6, 9]. The organisms commonly responsible for causing EP are E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, citrobacter, and, rarely, yeast [10, 11]. If left untreated, the condition is uniformly fatal. Acute pyelonephritis is a multifocal infection of one or both kidneys. Patients with uncomplicated pyelonephritis usually exhibit resolution of all symptoms within 72 h of the commencement of appropriate antibiotic therapy. Patients who fail to improve should be imaged to detect complications, and according to the American College of Radiology Appropriateness Criteria, CT is the preferred modality for patients with a clinical presentation of acute pyelonephritis [12]. CT can show the severity of this condition in detail, including unilateral and bilateral involvement, focal or diffuse infection, the presence of focal swelling, and the presence of kidney enlargement and complications (renal or extrarenal abscess, gas production, obstruction). Several classification systems have been proposed to correlate imaging findings with subsequent prognosis and management of patients with EP. The mildest forms are confined to the collecting system or from loculated air-fluid collections in or adjacent to the kidneys. This may be amenable to percutaneous drainage, as occurred in our case. The more severe infections are characterized by the spread of gas into the renal parenchyma and can extend into the perinephric and paranephric spaces, often requiring an emergency nephrectomy [2]. Conventional radiographs may demonstrate a cluster of mottled lucencies within the kidneys. Ultrasonography shows echogenic foci with “dirty” shadowing within the kidneys. On the CT, collections of gas are seen directly as hypoattenuating foci in the renal lodge. There was no consensus on the management of EP based on random-
17.9 mg/dL (reference value: 0.01–0.82 mg/dL). The urine analysis showed pyuria >73.99/high power field. Radiography and ultrasonography of the abdomen by the radiology department revealed no remarkable pathology, and abdominal computed tomography (CT) without contrast was ordered. The abdominal CT showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis, including the related ureter, compared to the right side, in addition to multiple millimetric stones located in the right kidney and the right ureter (Fig. 1). These imaging findings confirmed the diagnosis of EP of the right kidney with nephrolithiasis. After the patient underwent fluid resuscitation and a course of antibiotics with piperacillin–tazobactam for sepsis, in addition to emergent placement of a percutaneous nephrostomy, she was admitted to the urology department. Three days later, the urine culture grew Escherichia coli and her antibiotic was changed to meropenem accordingly. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis (Fig. 2). The patient was discharged from the urology service 10 days post-procedure with instructions for follow-up.
Discussion Kelly and MacCallum [3, 4] first described EP in 1898. It is an acute necrotizing parenchymal and perianal infection caused by gas-forming uropathogens [3, 5, 6]. Predisposing factors include gas-forming bacteria, high tissue glucose, defective immune responses, and impaired tissue perfusion [7]. Diabetic patients account for more than 90%–96% of cases [2, 8], and
ISSN 2061-1617 © 2016 Akadémiai Kiadó, Budapest
Control abdominal computed tomography of the patient after drainage. The gas has disappeared, but hydronephrosis and nephrolithiasis in right kidney remain (arrows)
30
Interventional Medicine & Applied Science
Emphysematous pyelonephritis
ized controlled trials, so treatment decisions mainly depend on the clinical condition of the patients, along with the imaging findings.
2. Huang JJ, Tseng CC: Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 160, 797–805 (2000) 3. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M: Emphysematous pyelonephritis. J Urol 131, 203–208 (1984) 4. Kelly HA, MacCallum WG: Pneumaturia. JAMA 31, 375–381 (1898) 5. Ouellet LM, Brook MP: Emphysematous pyelonephritis: an emergency indication for the plain abdominal radiograph. Ann Emerg Med 17, 722–724 (1988) 6. Evanoff GV, Thompson CS, Foley R, Weinman EJ: Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 83, 149–154 (1987) 7. Chen KW, Huang JJ, Wu MH, Lin XZ, Chen CY, Ruaan MK: Gas in hepatic veins: a rare and critical presentation of emphysematous pyelonephritis. J Urol 151, 125–126 (1994) 8. Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ: Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis 46, 432–439 (2005) 9. Cook DJ, Achong MR, Dobranowski J: Emphysematous pyelonephritis. Complicated urinary tract infection in diabetes. Diabetes Care 12, 229–232 (1989) 10. Andersen JB: Pyelonephritis emphysematosa. En alvorlig komplikation til diabetes mellitus. Ugeskr Laeger 154, 1419–1421 (1992) 11. Wang JM, Lim HK, Pang KK: Emphysematous pyelonephritis. Scand J Urol Nephrol 41, 223–229 (2007) 12. Sandler CM, Amis ES Jr, Bigongiari LR, Bluth EI, Bush WH Jr, Choyke PL, Fritzsche P, Holder L, Newhouse JH, Segal AJ, Resnick MI, Rutsky EA: Imaging in acute pyelonephritis. American College of Radiology. ACR Appropriateness Criteria. Radiology 215, 677–681 (2000)
Conclusions Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make an early diagnosis and to navigate management of the disease. *** Funding sources: No financial support was received for this study. Authors’ contribution: EEÜ and YŞ developed the concept and performed the drafting of the article; AK and GCT performed the preparation and revision of the article; and OO and CT performed the acquisition of data. Conflict of interest: The authors declare no conflicts of interest.
References 1. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T: Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 49, 343–346 (1997)
Interventional Medicine & Applied Science
31
ISSN 2061-1617 © 2016 Akadémiai Kiadó, Budapest
