Emphysematous

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DANIEL

From

1898

nephnitis mented extended

Pyelonephritis

S. KIM,’

MERLIN

E. WOESNER,

to

1975,

39 cases

of emphysematous

have

been

reported

[1

by

abdominal to

knowledge,

the

CT lesser

previously

in which sac

involvement

2].

,

is

of the

The the

case

disease

To

has not

by Computed

F. HOWARD,

AND

our

K. OLSON

Discussion Emphysematous Case

Report

often

performed

in Mexico

5 months

before

(fig.

2). Because

with

this

all been

reported

antibiotic tomy [4,

with

with

There

involvement

scan to

be

or

Pseudomonas, aerobacter have consists

and/or

,

poor rate

made by urography.

of

nephrec-

regardless

of

generally

re-

added

the

the

posterior

intomo-

demonstrated and pelviocalyceal

through was

plain abdominal In our case, CT

emphysematous or traditional

Tomography parenchyma

extension

fascia.

contiguous tended

tract

surgical

generally

more extensive plain radiography

examination. of the renal

Gerota’s CT

however, Klebsiella

mortality

diagnosis can and excretory

graphic physema

system

urinary the

of the gastrointestinal

7]. Treatment

a 50%-55%

scan documented volvement than

of the patient’s

and

most of the

[2, 6].

Correct radiography

moribund condition and the extent of the emphysematous process shown by CT, surgical drainage of the loft kidney was performed rather than nephrectomy. Additional drainage was used deep to the renal and perirenal area, guided by the CT

those

E. co/i;

,

from

therapy, su rgical d rainage 5]. Overall prognosis is

therapy, ported

include

[1

entity

to one-half

have associated cultured

commonly aeruginosa,

a rare

One-third

condition

specimens

tract, most Aerobacter

is

[1-3].

Organisms

drainage

admis-

pyelonephnitis

in diabetics

obstruction.

sion. The patient’s condition deteriorated rapidly after admission requiring endotrachoal intubation with respiratory assistance and cardiac monitoring. Blood and urine cultures grew E. co/i. Abdominal radiography on day 3 revealed left emphysematous pyelonephritis (fig. 1A). High dose excretory urography with tomograms showed no opacification of the renal parenchyma or collecting systems bilaterally (fig. 1B). CT scan later the same day revealed extension of the emphysematous process to the splenic capsule, lesser sac, and posterior portion of the

recess

seen

patients

A 67-year-old Mexican American man with known but poorly treated diabetes mellitus for 8 years had fever and chills for 18 hr. Physical examination revealed minimal left costovertebral angle tenderness; however, no abdominal mass was palpated and the abdomen was negative for rigidity or rebound tenderness. No diabetic retinopathy was noted. Urinalysis showed 70 leukocytes, one erythrocyte, and minimal glucose. Initial blood sugar was 746 mg/100 ml. Medical history included a suprapu-

costodiaphragmatic

LINDA

admission.

been

reported.

bic prostatoctomy

Tomography

findings. Repeat CT scan 3 weeks later showed significant improvement of the emphysematous process and no gas was noted in the lesser sac. The patient underwent left nephrectomy 3 weeks later and was discharged in fair condition 82 days after

docuprocess

here.

sac

THORA

pyelo-

first

reported

lesser

Demonstrated

the

renal

also

tomographic

of the

paravertebral

information

that

portion

of

the the

em-

capsule

to

evidence

of

space.

The

process

ex-

diaphragmatic

Fig. 1 -A, Abnormal (arrows) in left upper

gas collection

quadrant in re gion of left kidney. B, Gas surrounds emphysematous left kidney and upper ureter and has dissected into paravertebral space and toward splenic capsule. No opacification of renal collecting systems.

..“..--

...-.-

-.

All authors: Department quests to 0. 5. Kim. I

132:287-285, © 1979 American

AJR

February Roentgen

-

-.

of I

1979 Ray Society

..._ionOctoberL. White Memorial

..8. Medical Center,

287

1720 Brooklyn

Avenue,

Los Angeles,

California

90033. Address

0361-803X/79/1322-0287

reprint

re-

$0.00

CASE

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288

Fig.

urogram.

2.-A, Emphysematous pyelonephritis B, Gas extends through paravertebral

recess, splenic capsule, we feel that CT scanning information

to guide

of left

kidney.

Residual

planning.

REFERENCES 1 . Langston CS, Pfister AC: Renal and review ofthe literature.AJR

emphysema: 110:778-786,

2. Dunn SA, OeWolf

A: Emphysematous

pyelo-

by nephrectomy.

J Urol

WC, Gonzalez

nephritis: report of 3 cases 114:348-350, 1975

treated

contrast

in parenchyma

AJR:132,

of right

kidney

was

not

seen

February

on previous

1979

excretory

space into lesser sac (arrows).

and lesser sac. On this basis, provides more precise anatomic

surgical

REPORTS

a case 1970

report

3. Goergen TG: Unusual abdominal gas collection. JAMA 239:347-348, 1978 4. Murphy JF, Fred HL, Carlson J: Renal and perirenal gas in a diabetic man.JAMA 237:801-802, 1977 5. Rosenberg JW, Quader A, Brown JS: Renal emphysema. Urology 1 :237-239, 1973 6. Schainuck LI, Fouty A, Cutler RE: Emphysematous pyelonephritis: a new case and review of previous observations. AmJMed44:134-139, 1968 7. Bliznak J, Ramsey J: Emphysematous pyelonephritis. Clin Radiol 23:61-64, 1972