Vol. 114, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
EMPHYSEMATOUS PYELONEPHRITIS: REPORT OF 3 CASES TREATED BY NEPHRECTOMY STEPHEN R. DUNN, WILLIAM C. DEWOLF
AND
RICARDO GONZALEZ
From the Department of Urologic Surgery, University of Minnesota College of Health Sciences, Minneapoffs, Minnesota
ABSTRACT
Three cases of emphysematous pyelonephritis are presented. All 3 patients were diabetics, they all had Escherichia coli and there was evidence of ureteral obstruction in 1 case only. All 3 patients underwent nephrectomy and survived. Initial evaluation should be performed to rule out ureteral obstruction. Treatment should consist of a brief trial of high dose antibiotic therapy with serious consideration of nephrectomy in the face of persistent symptoms or gas. Incision and drainage are reserved for poor surgical risk patients. All patients should remain on antibacterial therapy and have frequent follovvup examinations. Emphysematous pyelonephritis is uncommon and presents a problem in management. 1-• Since first described in 1898 only 39 cases have been reported. Controversy still exists between advocates of medical versus surgical therapy .7 Our recent experience with 3 cases of emphysematous pyelonephritis helps to elucidate the natural history of this disease and provides guide lines for successful management. CASE REPORTS
Case 1. A 65-year-old diabetic woman was admitted to the hospital with a 4-day history of right upper quadrant pain, diarrhea and temperature to 104F. There was no history of urologic disease. Blood pressure was 110/70 mm. Hg, pulse 120 per minute and temperature 102.4F. A tender, firm mass was palpable in the right upper quadrant. The white blood count (WBC) was 22,400 per cu. mm., blood glucose 130 mg. per 100 ml., blood urea nitrogen (BUN) 50 mg. per 100 ml. and serum creatinine 2.2 mg. per 100 ml. The creatinine clearance was 18 ml. per minute. Blood and urine cultures yielded Escherichia coli in significant numbers. An excretory urogram (IVP) revealed a normalappearing left kidney. There was non-visualization on the right side and gas was noted in the region of the right kidney. Right renal and perirenal gas was confirmed with nephrotomography (fig. 1). The patient was initially treated with gentamicin and then ampicillin but the symptoms continued and urologic consultation was obtained 4 days later. A right retrograde pyelogram revealed no obstruction. Because of continued sepsis, despite medical therapy, a right renal exploration was Accepted for publication March 21, 1975. Read at annual meeting of North Central Section, American Urological Association, Columbus, Ohio, September 18-21, 1974. 348
done. There was intense perinephritis and the entire kidney was edematous and dusky. Multiple cortical abscesses were noted and nephrectomy was performed. Convalescence was unremarkable. The patient was discharged from the hospital with a BUN of 34 mg. per cent, creatinine 1.8 mg. per cent and creatinine clearance 33 ml. per minute. Case 2. A 65-year-old woman was admitted to the hospital with diabetic ketoacidosis and E. coli urinary tract infection. An IVP revealed non-visualization on the right side with intrarenal and perirenal gas (fig. 2). The patient was treated with appropriate diabetic management and antibiotics and was alert and afebrile a week later. Physical examination at that time was unremarkable. The hemoglobin was 8.6 gm. per 100 ml., WBC 5,300 per cu. mm., BUN 16 mg. per 100 ml. and serum creatinine 1.2 mg. per 100 ml. Creatinine clearance was 36 ml. per minute. After 10 days of medical therapy the urine culture was sterile. However, repeat IVP showed persistent non-visualization on the right side as well as gas in and around the lower pole. Because of these findings right renal exploration was done. Severe perinephric inflammation was present and a large lower pole abscess was entered. The kidney was judged to be non-viable and nephrectomy was performed. The patient was discharged from the hospital 10 days postoperatively. Microscopic examination of the kidney revealed acute and chronic pyelonephritis with intrarenal and perinephric abscess formation. Cultures of the abscess yielded E. coli. On followup examination 4 months later the patient was feeling well with a BUN of 48 mg. per 100 ml. and a creatinine of 2.1 mg. per 100 ml. Case 3. A 51-year-old diabetic woman was admitted to the hospital with a 2-day history of malaise, left flank pain, chills and fever. Physical examination revealed the patient to be acutely ill. Temperature was 103.5F, pulse 92 per minute and
EMPHYSEMATOUS PYELONEPHRITIS
blood pressure 150/95 mm. Hg. There was marked left costovertebral angle tenderness. The hemoglobin was 16 gm. per 100 ml. and WBC was 27,100 per cu. mm. Urinalysis revealed 1 plus protein, 4 plus glucose and a pH of 6; no cells or bacteria were noted. Blood was 411 mg. per 100 ml. and serum creatinine was 1.4 mg. per 100 rn.L Urine culture yielded E. coli greater than 100,000 colonies per mL and blood cultures were for E. coli. An IVP reveaied a normal right and
non-visualization on the left side with evidence of gas in the collecting system, renal parenchyma and perinephric tissues (fig. 3). Initial treatment included antibiotic therapy with keflin and gentamicin. By 2 days following hospitalization the patient was unimproved and retrograde pyelography revealed an obstruction at the ureteropelvic junction. No stones could be an intense perinephritis identified. At was again encountered. The kidney was large and edematous with multiple small cortical abscesses. An attempt was made to the proximal ureter but it was found to be necrotic and friable, and separated dissection. the performed. ,_,ACUmC>r rapidly, the discharged from the hospital with a creatinine clearance of 58 ml. per minute. Microscopic examination of the specimen revealed acute and chronic pyelonephritis with multiple microabscesses. DISCUSSION
FIG. 1. Case 1. A, IVP demonstrates non-visualization and upper pole parenchymal gas on right side. B, nephrotomogram confirms presence of gas within renal parenchyma. C, x-ray of specimen after nephrectomy shows diffuse parenchymal gas.
Thirty-nine cases of ernphysematous pyelonephritis have been reported, with an over-all mortality rate of 33 1/:i per cent (see table). The condition occurs in the severely infected kidney when the glucose is fermented to produce carbon dioxide and hydrogen, which accumulate in the renal parenchyma and perirenal tissues. The most commonly implicated organism is E. coli but Proteus and Aerobacter species as well as other facultative anaerobes may be responsible. Carbon dioxide and hydrogen are readily diffusible and their persistence despite therapy is graphic evidence that the infection has not been controlled and that abscess formation has occurred. Emphysematous pyelonephritis can occur in the diabetic with or without obstruction. However, in the non-diabetic it is nearly always associated with ureteral obstruction. 4 Diagnosis is made the demonstration of gas in the renal parenchyma or perinephritic tissues in a patient who presents with the clinical findings of
FIG ..2. Case 2. A,
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
EMPHYSEMATOUS PYELONEPHRITIS: REPORT OF 3 CASES TREATED BY NEPHRECTOMY STEPHEN R. DUNN, WILLIAM C. DEWOLF
AND
RICARDO GONZALEZ
From the Department of Urologic Surgery, University of Minnesota College of Health Sciences, Minneapoffs, Minnesota
ABSTRACT
Three cases of emphysematous pyelonephritis are presented. All 3 patients were diabetics, they all had Escherichia coli and there was evidence of ureteral obstruction in 1 case only. All 3 patients underwent nephrectomy and survived. Initial evaluation should be performed to rule out ureteral obstruction. Treatment should consist of a brief trial of high dose antibiotic therapy with serious consideration of nephrectomy in the face of persistent symptoms or gas. Incision and drainage are reserved for poor surgical risk patients. All patients should remain on antibacterial therapy and have frequent follovvup examinations. Emphysematous pyelonephritis is uncommon and presents a problem in management. 1-• Since first described in 1898 only 39 cases have been reported. Controversy still exists between advocates of medical versus surgical therapy .7 Our recent experience with 3 cases of emphysematous pyelonephritis helps to elucidate the natural history of this disease and provides guide lines for successful management. CASE REPORTS
Case 1. A 65-year-old diabetic woman was admitted to the hospital with a 4-day history of right upper quadrant pain, diarrhea and temperature to 104F. There was no history of urologic disease. Blood pressure was 110/70 mm. Hg, pulse 120 per minute and temperature 102.4F. A tender, firm mass was palpable in the right upper quadrant. The white blood count (WBC) was 22,400 per cu. mm., blood glucose 130 mg. per 100 ml., blood urea nitrogen (BUN) 50 mg. per 100 ml. and serum creatinine 2.2 mg. per 100 ml. The creatinine clearance was 18 ml. per minute. Blood and urine cultures yielded Escherichia coli in significant numbers. An excretory urogram (IVP) revealed a normalappearing left kidney. There was non-visualization on the right side and gas was noted in the region of the right kidney. Right renal and perirenal gas was confirmed with nephrotomography (fig. 1). The patient was initially treated with gentamicin and then ampicillin but the symptoms continued and urologic consultation was obtained 4 days later. A right retrograde pyelogram revealed no obstruction. Because of continued sepsis, despite medical therapy, a right renal exploration was Accepted for publication March 21, 1975. Read at annual meeting of North Central Section, American Urological Association, Columbus, Ohio, September 18-21, 1974. 348
done. There was intense perinephritis and the entire kidney was edematous and dusky. Multiple cortical abscesses were noted and nephrectomy was performed. Convalescence was unremarkable. The patient was discharged from the hospital with a BUN of 34 mg. per cent, creatinine 1.8 mg. per cent and creatinine clearance 33 ml. per minute. Case 2. A 65-year-old woman was admitted to the hospital with diabetic ketoacidosis and E. coli urinary tract infection. An IVP revealed non-visualization on the right side with intrarenal and perirenal gas (fig. 2). The patient was treated with appropriate diabetic management and antibiotics and was alert and afebrile a week later. Physical examination at that time was unremarkable. The hemoglobin was 8.6 gm. per 100 ml., WBC 5,300 per cu. mm., BUN 16 mg. per 100 ml. and serum creatinine 1.2 mg. per 100 ml. Creatinine clearance was 36 ml. per minute. After 10 days of medical therapy the urine culture was sterile. However, repeat IVP showed persistent non-visualization on the right side as well as gas in and around the lower pole. Because of these findings right renal exploration was done. Severe perinephric inflammation was present and a large lower pole abscess was entered. The kidney was judged to be non-viable and nephrectomy was performed. The patient was discharged from the hospital 10 days postoperatively. Microscopic examination of the kidney revealed acute and chronic pyelonephritis with intrarenal and perinephric abscess formation. Cultures of the abscess yielded E. coli. On followup examination 4 months later the patient was feeling well with a BUN of 48 mg. per 100 ml. and a creatinine of 2.1 mg. per 100 ml. Case 3. A 51-year-old diabetic woman was admitted to the hospital with a 2-day history of malaise, left flank pain, chills and fever. Physical examination revealed the patient to be acutely ill. Temperature was 103.5F, pulse 92 per minute and
EMPHYSEMATOUS PYELONEPHRITIS
blood pressure 150/95 mm. Hg. There was marked left costovertebral angle tenderness. The hemoglobin was 16 gm. per 100 ml. and WBC was 27,100 per cu. mm. Urinalysis revealed 1 plus protein, 4 plus glucose and a pH of 6; no cells or bacteria were noted. Blood was 411 mg. per 100 ml. and serum creatinine was 1.4 mg. per 100 rn.L Urine culture yielded E. coli greater than 100,000 colonies per mL and blood cultures were for E. coli. An IVP reveaied a normal right and
non-visualization on the left side with evidence of gas in the collecting system, renal parenchyma and perinephric tissues (fig. 3). Initial treatment included antibiotic therapy with keflin and gentamicin. By 2 days following hospitalization the patient was unimproved and retrograde pyelography revealed an obstruction at the ureteropelvic junction. No stones could be an intense perinephritis identified. At was again encountered. The kidney was large and edematous with multiple small cortical abscesses. An attempt was made to the proximal ureter but it was found to be necrotic and friable, and separated dissection. the performed. ,_,ACUmC>r rapidly, the discharged from the hospital with a creatinine clearance of 58 ml. per minute. Microscopic examination of the specimen revealed acute and chronic pyelonephritis with multiple microabscesses. DISCUSSION
FIG. 1. Case 1. A, IVP demonstrates non-visualization and upper pole parenchymal gas on right side. B, nephrotomogram confirms presence of gas within renal parenchyma. C, x-ray of specimen after nephrectomy shows diffuse parenchymal gas.
Thirty-nine cases of ernphysematous pyelonephritis have been reported, with an over-all mortality rate of 33 1/:i per cent (see table). The condition occurs in the severely infected kidney when the glucose is fermented to produce carbon dioxide and hydrogen, which accumulate in the renal parenchyma and perirenal tissues. The most commonly implicated organism is E. coli but Proteus and Aerobacter species as well as other facultative anaerobes may be responsible. Carbon dioxide and hydrogen are readily diffusible and their persistence despite therapy is graphic evidence that the infection has not been controlled and that abscess formation has occurred. Emphysematous pyelonephritis can occur in the diabetic with or without obstruction. However, in the non-diabetic it is nearly always associated with ureteral obstruction. 4 Diagnosis is made the demonstration of gas in the renal parenchyma or perinephritic tissues in a patient who presents with the clinical findings of
FIG ..2. Case 2. A,
