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Kidney International (2014) 85, 1246; doi:10.1038/ki.2013.379

Emphysematous pyelonephritis: disappearing kidneys Rapur Ram1, Peddi Sandeep1, Annapindi Venkatasatya Surya Naga Sridhar1, Chennu Krishna Kishore1 and Vishnubotla Siva Kumar1 1

Department of Nephrology, Sri Venkateshwara Institute of Medical Sciences, Tirupati, India

Correspondence: R. Ram, Department of Nephrology, Sri Venkateshwara Institute of Medical Sciences, Tirupati, India. E-mail: [email protected]

Figure 1 | Computerized tomography abdomen: sagittal section.

A 51-year-old man with type 2 diabetes mellitus for 10 years and hypertension for 8 years, who was a smoker and an alcoholic, presented with a history of fever, chills, and rigor of 4 days; abdominal pain and distension of 3 days; jaundice and anuria of 1 day duration. He had been binge drinking for 2 days before admission and had not taken insulin for several days. Examination revealed jaundice, tachypnea, tachycardia, a blood pressure of 90/70 mm Hg, and diffuse abdominal tenderness, with no guarding or rigidity. Investigations showed the following results: random blood glucose, 385 mg/dl; serum creatinine, 8.5 mg/dl; blood urea, 185 mg/dl; serum sodium, 142 mEq/l; serum potassium, 5.5 mEq/l; serum bilirubin, 8.0 mg/dl; hemoglobin, 13.5 g/dl; total leukocyte count, 30,800/mL; platelet count, 85,000/mL; and urine and blood cultures, sterile. Ultrasound abdomen showed multiple gas shadows in both the kidneys. Computerized tomography scan of the abdomen (Figure 1 and Supplementary Figure S1 online) revealed that the major parts of kidneys were replaced by gas, with only shreds of renal tissue visible. On the same day, bilateral ultrasound-guided percutaneous drainages were placed (Supplementary Figure S2 online). The pus revealed the growth of Escherichia coli. He was treated with pipercillin–tazobactum and aztreonam 1246

for 3 weeks. There was improvement in fever and hypotension. However, he remained dialysis dependent. Emphysematous pyelonephritis (EPN) is a rare lifethreatening disease. The presentation may vary from mild abdominal pain to circulatory failure. First described in 1898, EPN appeared to be influenced by four factors: gas-forming bacteria, high tissue glucose, impaired tissue perfusion, and a defective immune response. Diabetes mellitus accounts for 70–90% of all patients. The organisms most commonly associated are E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Aerobacter aerogenes, and Citrobacter. Rarely, Candida, Crpytococcus, and Aspergillus are also reported to be causative organisms. The exact frequency of bilateral EPN is unknown. With current therapy, the mortality is between 10 and 40%. Currently, there is no guideline on treatment; medical treatment and surgical management should be considered concurrently. SUPPLEMENTARY MATERIAL Figure S1. CT scan abdomen: coronal section. Figure S2. Plain radiograph abdomen. Supplementary material is linked to the online version of the paper at http://www.nature.com/ki Kidney International (2014) 85, 1246

Emphysematous pyelonephritis: disappearing kidneys.

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