BILATERAL EMPHYSEMATOUS PYELONEPHRITIS BRUCE A. LOWE, M.D. MATTHEW D. POAGE, M.D. From the Division of Urology, Oregon Health Sciences University, Portland, Oregon
ysematous pyelonephritis is an uncommon and serious infection associated iform bacteria. Bilateral involvement is rare with only 10 reported cases in the 'ompt and aggressive management is required to salvage these patients. Preser:tion using broad-spectrum antibiotics and surgical drainage provides the ~se patients. Three new cases are presented with a brief review of the results of ,eported cases.
trenchyma, collecting sys,ace indicates emphysemaan uncommon necrotizing, infection associated with acteria. It occurs predomiad has a reported mortality t.1 Fewer than 60 cases are t authors recommending ~my or open drainage as t can be minimal or extenin the intrarenal collecting ble prognosis and is easily rely. 2 Extensive parenchyinfections present difficult by multimodal therapy . A staging system recently [i and associates 2 lists Stage enal parenchyma or in the ge II as gas within the renal he perirenal tissues, and through the Gerota fascia lent. Only 10 patients with ttous pyelonephritis are reh literature. We report an s presenting with bilateral Jew the management of bims pyelonephritis.
[991
/
Case Reports Case 1 A fifty-two-year-old man with a history of alcoholism and insulin-dependent diabetes presented with sepsis and oliguric renal failure. A palpable left abdominal mass was present on examination. Serum ereatinine was 7.7, white blood cell (WBC) count greater than 30,000/ mL, and pyuria. Eseherichia coli was cultured in both urine and blood. An undefined gas pattern noted on plain abdominal radiographs was shown by computerized tomography (CT) scan to involve the renal parenchyma bilaterally. No left renal function was noted. A left nephrectomy was performed after starting broad-spectrum antibiotics and fluid resuscitation. Continued deterioration of his condition resulted in adult respiratory distress syndrome, thrombocytopenia, and uncontrolled ketoacidosis. A repeat CT scan performed one week postnephrectomy demonstrated a right perirenal abscess and intraparenchymal air. A necrotic right kidney was removed in a second exploration. Persistent bleeding necessitated a re-exploration and evacuation of hematoma. A pseudomonas pneumonia followed, and the patient died three weeks after presentation.
VOLUME XXXVII, NUMBER 3
229
FIGURE 1. Case 2. Plain abdominal radiograph displaying classic pattern of abnormal perirenal gas collections surrounding both kidneys. Case 2 A forty-seven-year-old diabetic male American Indian with chronic alcoholism was seen for low-back pain and nausea of one-week duration. Scleral icterus, mental confusion, and a 6 x 7-em mass at the left costal margin were noted at admission. Serum glucose was 888 rag/ dL, creatinine 4.7 mg/dL, WBC count 20,000/ mL, and packed fields of leukocytes and bacteria on urinalysis. Clotting studies were normal. Bilateral perinephric air on plain abdominal xray films (Fig. 1) was shown to involve the renal parenchyma and perirenal spaces bilaterally by CT scan (Fig. 2). Bilateral fluid collections and diffuse air were noted to extend along the right ureter into and involving the bladder wall (Fig. 2B). Broad-spectrum antibiotics, fluid resuscitation, and intravenous insulin were started immediately. DTPA nuclear medicine scans demonstrated no function bilaterally. Klebsiella pneumoniae was cultured from both the blood and urine. Initial bilateral percutaneous drainage of the perirenal fluid collections produced only clotted blood and a small amount of purulent material. Ureteral catheterization was unsuccessful. Following this urine output improved and the serum creatinine stabilized. A febrile episode 230
FICURE 2. Case 2. (A) c r scan of upper abdoNf*! demonstrating gas collections involving both ; ]ossa and both renal parenchyma. (B) P e l v i ~ scan demonstrating involvement o] right b l a ~ wall. "~q~ associated with mental confusiol prompted bilateral flank explorai perirenal hematomas with only a of purulent fluid were evacuated ited parenchymal destruction wi cortex intact bilaterally. The pc were drained and medical mana~ ued. Gradual improvement c several weeks resulted in dischar~ ter admission with a serum ere mg/dL. A radionuclide renal strated nearly normal left functic ished but significant function of ney.
Case 3 ~;~ ~ A fifty-six-year-old male diabetic e o n ~ r ~ by diet presented with a twelve-hour h',~o~!~:!~ left flank pain and an episode of E. coli p ~ : nephritis two months previously Oral temi ~, ~ ture was 39°C associated with shahng~ and marked tenderness in the left flank. , ~
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l;Fir;ugE 3. case 3. ltenal tomogram illustrating bi!iai)ral air pyelograms.
~6unt was 12,000/mL, serum creatinine 2.7 mg/dL, with marked pyuria and baeteriuria on ~it)~Iysis. Tomography revealed bilateral air i~)el6grams with left hydronephrosis (Fig. 3). N6 parenchymal air was identified by CT scan. Bmadispectrum antibiotics and fluid resuscita~0n were started immediately. A left pereuta~eous nephrostomy drained approximately 100 INL of purulent fluid. Laboratory and clinical l;~arameters returned to normal except for perl~istent E. coli in the urine. Antegrad-e nephros!0gram revealed a lucent filling defect in the mid portion of the left ureter and ealiceal =! . . . . . Iet!anges consistent with papillary necrosis. A ~ecrotic renal papilla was removed ureteroseoipieally using a stone basket Urine cultures
i
cleared within twenty-four hours, and the patient was discharged without further complications. Comment Emphysematous pyelonephritis is a potentially fatal complication of acute pyelonephritis seen in diabetics. The coliform bacteria, E. eoli, Klebsiella, or Aerobaeter are reported in all eases 1 except 1 ease associated with Candida albieans. 3 The mechanism of gas formation is unclear. Fermentation of glucose, present in high concentrations in the tissues of poorly controlled diabetics, to form carbon dioxide and hydrogen is one possible explanation. 2 However, the rarity of emphysematous pyelonephritis and the frequency of eoliforms in urinary tract infections in diabetics indicate another etiology. Neerotizing infections are associated with a poor tissue and vascular response produeing a substrate of necrotic tissue which can be used for the subsequent generation of hydrogen and carbon dioxide, t,2,4 Gas formation after a traumatic renal infarction 5 and in renal tumors following angioinfaretion ~ support the role of an impaired host response in emphysematous pyelonephritis. Emphysematous pyelonephritis should be considered in any diabetic or patient with compromised or isehemie renal tissue and a severe urinary tract infection. Plain x-ray films of the abdomen will identify the abnormal air patterns in most patients. A noneontrasted CT scan will provide the greatest information and should be obtained in all patients. Urine and
TABLE I.
S u m m a r y o] 13 reported cases* o] bilateral emphysematous pyelonephritis
Case Age/ No. Sex 1
52/F
2 3 4 5 6 7 8 9 10 11 12 13
46/F 62/M 54/F 47/M 55/M 73/F 69/M 68/M ?/M 52/M
47/M 56/M
Therapy I&D$ right kidney Right nephrectomy I&D bilateral I&D bilateral Medical Bilateral nephreetomy I&D, left nephreetomy Medical Bilateral nephreetomy Medical Bilateral nephreetomy I&D bilateral I&D bilateral
Status Organism Source Dead E. eoli Gillies and Flocks1° Dead E. eoli Harrison and Baileyn Alive E. coli Plaggemeyer et al. ~2 Alive E. eoli Costa '3 Dead E. eoli Kumar and Rao t4 Alive E. coli Hawes et al.15 Alive E. coli Zabbo et al.S Dead E. coli Klein et al.1 Dead E. coli Klein et al. Dead E. eoli Ahlering et al. 9 Dead E. eoli Lowe and Poage Alive Klebsiella Lowe and Poage Alive E. eoli Lowe and Poage
*Includes 3 cases reported herein. Tlneision and drainage.
/
M A R C H 1991
/
V O L U M E XXXVII, N U M B E R 3
231
blood cultures are important for appropriate antibiotic selection. Historically, management of this difficult condition has included bilateral nephreetomy, antibiotics, combinations of both, or drainage and antibiotics. Review of the 10 reported eases show that medical management alone was employed in 3 patients, all of whom died. Bilateral nephreetomy, advocated by several authors in unilateral emphysematous pyelonephritis, was used in 3 patients, 1 in the current report with only 1 survivor. Unilateral nephreetomy, removing the most severely compromised renal unit and parenteral antibiotics were attempted in 2 patients with 1 survivor treated by open drainage of the eontralateral kidney in conjunction with the nephreetomy. Incision and drainage combined with antibiotics was used in 4 patients, with 3 survivors. The only death occurred in a patient treated in the pre-antibiotie era by simple drainage alone. Gas in the collecting systems only was managed successfully in this group by closed drainage alone (Table I). Combined modality therapy employing broad-spectrum antibiotics and drainage with preservation of renal parenehyma offers the best potential survival. Unless the renal parenehyma is necrotic bilaterally, nephreetomy and subsequent dialysis are not necessary. This approach has been used successfully in the management of unilateral emphysematous pyelonephritis and is the treatment of choice for bilateral involvement.l.7-° Preservation of renal
parenchyma is an important life-saving in these critically ill Portla:
References 1. Klein FA, Smith MJ, Viek CW, and matous pyelonephritis: diagnosis and treal (1986). 2. Michaeli J, et ah Emphysematous 131:203 (1984). 3. Johnson JR, Ireton RC, and Lipsl~ pyelonephritis, J Urol 136:80 (1986). 4. Freiha FS, Messing DM, and Gross pyelonephritis, JCE Urol 18:9 (1979). 5. Subramanyam BR, Leufeurs RS, an emphysema secondary to traumatic renal J 2:53 (1980). 6. Rankin RN: Gas formation after ren without abscess: a benign occurrence, Rad 7. Hudson MA, Weyman PJ, Van Der¥ WJ: Emphysematous pyelonephritis: suec percutaneous drainage, J Urol 136:884 (1 8. Zabbo A, Montie JE, Popowniak KI_ lateral emphysematous pyelonephritis, Ur 9. Ahlering TC, et ah Emphysematm year experience with 13 patients, J Urol 1 10. Gillies CL, and Flocks R: Spontane emphysema, AJR 46:173 (1941). 11. Harrison JH, and Bailey OT: Sign pyelonephritis diabetes mellitus, JAMA iI 12. Plaggemeyer HW, Weltman CG, S maltz JD: Pneumo-pyo-nephrosis of B. Hosp Bull 25:79 (1947). 13. Costas S: Renal and perirenal emF 311 (1972). 14. Kumar D, and Rao BR: Bilateral nephritis, Urology 20:96 (1982). 15. Hawes S, et ah Emphysematous Surg 2:191 (1983).
' i~!i~
232
UROLOGY / MARCH 1991 / VOLUME XXXVII, N
~
~
•
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ysematous pyelonephritis is an uncommon and serious infection associated iform bacteria. Bilateral involvement is rare with only 10 reported cases in the 'ompt and aggressive management is required to salvage these patients. Preser:tion using broad-spectrum antibiotics and surgical drainage provides the ~se patients. Three new cases are presented with a brief review of the results of ,eported cases.
trenchyma, collecting sys,ace indicates emphysemaan uncommon necrotizing, infection associated with acteria. It occurs predomiad has a reported mortality t.1 Fewer than 60 cases are t authors recommending ~my or open drainage as t can be minimal or extenin the intrarenal collecting ble prognosis and is easily rely. 2 Extensive parenchyinfections present difficult by multimodal therapy . A staging system recently [i and associates 2 lists Stage enal parenchyma or in the ge II as gas within the renal he perirenal tissues, and through the Gerota fascia lent. Only 10 patients with ttous pyelonephritis are reh literature. We report an s presenting with bilateral Jew the management of bims pyelonephritis.
[991
/
Case Reports Case 1 A fifty-two-year-old man with a history of alcoholism and insulin-dependent diabetes presented with sepsis and oliguric renal failure. A palpable left abdominal mass was present on examination. Serum ereatinine was 7.7, white blood cell (WBC) count greater than 30,000/ mL, and pyuria. Eseherichia coli was cultured in both urine and blood. An undefined gas pattern noted on plain abdominal radiographs was shown by computerized tomography (CT) scan to involve the renal parenchyma bilaterally. No left renal function was noted. A left nephrectomy was performed after starting broad-spectrum antibiotics and fluid resuscitation. Continued deterioration of his condition resulted in adult respiratory distress syndrome, thrombocytopenia, and uncontrolled ketoacidosis. A repeat CT scan performed one week postnephrectomy demonstrated a right perirenal abscess and intraparenchymal air. A necrotic right kidney was removed in a second exploration. Persistent bleeding necessitated a re-exploration and evacuation of hematoma. A pseudomonas pneumonia followed, and the patient died three weeks after presentation.
VOLUME XXXVII, NUMBER 3
229
FIGURE 1. Case 2. Plain abdominal radiograph displaying classic pattern of abnormal perirenal gas collections surrounding both kidneys. Case 2 A forty-seven-year-old diabetic male American Indian with chronic alcoholism was seen for low-back pain and nausea of one-week duration. Scleral icterus, mental confusion, and a 6 x 7-em mass at the left costal margin were noted at admission. Serum glucose was 888 rag/ dL, creatinine 4.7 mg/dL, WBC count 20,000/ mL, and packed fields of leukocytes and bacteria on urinalysis. Clotting studies were normal. Bilateral perinephric air on plain abdominal xray films (Fig. 1) was shown to involve the renal parenchyma and perirenal spaces bilaterally by CT scan (Fig. 2). Bilateral fluid collections and diffuse air were noted to extend along the right ureter into and involving the bladder wall (Fig. 2B). Broad-spectrum antibiotics, fluid resuscitation, and intravenous insulin were started immediately. DTPA nuclear medicine scans demonstrated no function bilaterally. Klebsiella pneumoniae was cultured from both the blood and urine. Initial bilateral percutaneous drainage of the perirenal fluid collections produced only clotted blood and a small amount of purulent material. Ureteral catheterization was unsuccessful. Following this urine output improved and the serum creatinine stabilized. A febrile episode 230
FICURE 2. Case 2. (A) c r scan of upper abdoNf*! demonstrating gas collections involving both ; ]ossa and both renal parenchyma. (B) P e l v i ~ scan demonstrating involvement o] right b l a ~ wall. "~q~ associated with mental confusiol prompted bilateral flank explorai perirenal hematomas with only a of purulent fluid were evacuated ited parenchymal destruction wi cortex intact bilaterally. The pc were drained and medical mana~ ued. Gradual improvement c several weeks resulted in dischar~ ter admission with a serum ere mg/dL. A radionuclide renal strated nearly normal left functic ished but significant function of ney.
Case 3 ~;~ ~ A fifty-six-year-old male diabetic e o n ~ r ~ by diet presented with a twelve-hour h',~o~!~:!~ left flank pain and an episode of E. coli p ~ : nephritis two months previously Oral temi ~, ~ ture was 39°C associated with shahng~ and marked tenderness in the left flank. , ~
UROLOGY
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MARCH 1991
/
"
VOLUME XXXVII,
.
~
l;Fir;ugE 3. case 3. ltenal tomogram illustrating bi!iai)ral air pyelograms.
~6unt was 12,000/mL, serum creatinine 2.7 mg/dL, with marked pyuria and baeteriuria on ~it)~Iysis. Tomography revealed bilateral air i~)el6grams with left hydronephrosis (Fig. 3). N6 parenchymal air was identified by CT scan. Bmadispectrum antibiotics and fluid resuscita~0n were started immediately. A left pereuta~eous nephrostomy drained approximately 100 INL of purulent fluid. Laboratory and clinical l;~arameters returned to normal except for perl~istent E. coli in the urine. Antegrad-e nephros!0gram revealed a lucent filling defect in the mid portion of the left ureter and ealiceal =! . . . . . Iet!anges consistent with papillary necrosis. A ~ecrotic renal papilla was removed ureteroseoipieally using a stone basket Urine cultures
i
cleared within twenty-four hours, and the patient was discharged without further complications. Comment Emphysematous pyelonephritis is a potentially fatal complication of acute pyelonephritis seen in diabetics. The coliform bacteria, E. eoli, Klebsiella, or Aerobaeter are reported in all eases 1 except 1 ease associated with Candida albieans. 3 The mechanism of gas formation is unclear. Fermentation of glucose, present in high concentrations in the tissues of poorly controlled diabetics, to form carbon dioxide and hydrogen is one possible explanation. 2 However, the rarity of emphysematous pyelonephritis and the frequency of eoliforms in urinary tract infections in diabetics indicate another etiology. Neerotizing infections are associated with a poor tissue and vascular response produeing a substrate of necrotic tissue which can be used for the subsequent generation of hydrogen and carbon dioxide, t,2,4 Gas formation after a traumatic renal infarction 5 and in renal tumors following angioinfaretion ~ support the role of an impaired host response in emphysematous pyelonephritis. Emphysematous pyelonephritis should be considered in any diabetic or patient with compromised or isehemie renal tissue and a severe urinary tract infection. Plain x-ray films of the abdomen will identify the abnormal air patterns in most patients. A noneontrasted CT scan will provide the greatest information and should be obtained in all patients. Urine and
TABLE I.
S u m m a r y o] 13 reported cases* o] bilateral emphysematous pyelonephritis
Case Age/ No. Sex 1
52/F
2 3 4 5 6 7 8 9 10 11 12 13
46/F 62/M 54/F 47/M 55/M 73/F 69/M 68/M ?/M 52/M
47/M 56/M
Therapy I&D$ right kidney Right nephrectomy I&D bilateral I&D bilateral Medical Bilateral nephreetomy I&D, left nephreetomy Medical Bilateral nephreetomy Medical Bilateral nephreetomy I&D bilateral I&D bilateral
Status Organism Source Dead E. eoli Gillies and Flocks1° Dead E. eoli Harrison and Baileyn Alive E. coli Plaggemeyer et al. ~2 Alive E. eoli Costa '3 Dead E. eoli Kumar and Rao t4 Alive E. coli Hawes et al.15 Alive E. coli Zabbo et al.S Dead E. coli Klein et al.1 Dead E. coli Klein et al. Dead E. eoli Ahlering et al. 9 Dead E. eoli Lowe and Poage Alive Klebsiella Lowe and Poage Alive E. eoli Lowe and Poage
*Includes 3 cases reported herein. Tlneision and drainage.
/
M A R C H 1991
/
V O L U M E XXXVII, N U M B E R 3
231
blood cultures are important for appropriate antibiotic selection. Historically, management of this difficult condition has included bilateral nephreetomy, antibiotics, combinations of both, or drainage and antibiotics. Review of the 10 reported eases show that medical management alone was employed in 3 patients, all of whom died. Bilateral nephreetomy, advocated by several authors in unilateral emphysematous pyelonephritis, was used in 3 patients, 1 in the current report with only 1 survivor. Unilateral nephreetomy, removing the most severely compromised renal unit and parenteral antibiotics were attempted in 2 patients with 1 survivor treated by open drainage of the eontralateral kidney in conjunction with the nephreetomy. Incision and drainage combined with antibiotics was used in 4 patients, with 3 survivors. The only death occurred in a patient treated in the pre-antibiotie era by simple drainage alone. Gas in the collecting systems only was managed successfully in this group by closed drainage alone (Table I). Combined modality therapy employing broad-spectrum antibiotics and drainage with preservation of renal parenehyma offers the best potential survival. Unless the renal parenehyma is necrotic bilaterally, nephreetomy and subsequent dialysis are not necessary. This approach has been used successfully in the management of unilateral emphysematous pyelonephritis and is the treatment of choice for bilateral involvement.l.7-° Preservation of renal
parenchyma is an important life-saving in these critically ill Portla:
References 1. Klein FA, Smith MJ, Viek CW, and matous pyelonephritis: diagnosis and treal (1986). 2. Michaeli J, et ah Emphysematous 131:203 (1984). 3. Johnson JR, Ireton RC, and Lipsl~ pyelonephritis, J Urol 136:80 (1986). 4. Freiha FS, Messing DM, and Gross pyelonephritis, JCE Urol 18:9 (1979). 5. Subramanyam BR, Leufeurs RS, an emphysema secondary to traumatic renal J 2:53 (1980). 6. Rankin RN: Gas formation after ren without abscess: a benign occurrence, Rad 7. Hudson MA, Weyman PJ, Van Der¥ WJ: Emphysematous pyelonephritis: suec percutaneous drainage, J Urol 136:884 (1 8. Zabbo A, Montie JE, Popowniak KI_ lateral emphysematous pyelonephritis, Ur 9. Ahlering TC, et ah Emphysematm year experience with 13 patients, J Urol 1 10. Gillies CL, and Flocks R: Spontane emphysema, AJR 46:173 (1941). 11. Harrison JH, and Bailey OT: Sign pyelonephritis diabetes mellitus, JAMA iI 12. Plaggemeyer HW, Weltman CG, S maltz JD: Pneumo-pyo-nephrosis of B. Hosp Bull 25:79 (1947). 13. Costas S: Renal and perirenal emF 311 (1972). 14. Kumar D, and Rao BR: Bilateral nephritis, Urology 20:96 (1982). 15. Hawes S, et ah Emphysematous Surg 2:191 (1983).
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