Vol. 115, May
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
EMPHYSEMATOUS PYELONEPHRITIS STEPHEN D. MCMURRAY,* FRJEl])RJCH C. LUFT, DOUGLAS R. MAXWELL
AND
STUART A. KLEIT
From the Renal Section, Department of Medicine, Indiana University School of Medicine and the Medicine Services, Indiana University and Veterans Administration Hospitals, Indianapolis, Indiana
ABSTRACT
Emphysematous pyelonephritis is a rare complication of urinary tract infection and generally occurs in patients with diabetes mellitus or urinary tract obstruction. We recently treated an 81-year-old diabetic woman with Klebsiella pneumoniae urinary tract infection and septicemia whose abdominal roentgenogram demonstrated a striking left pneumonephrogram as well as intraureteral and perirenal gas. The patient died despite intensive therapeutic efforts. Unfortunately, the prognosis for this severe necrotizing infection process remains unfavorable. The spontaneous generation of gas within and around the substance of the kidney is termed emphysematous pyelonephritis. 1 This clinical entity is a rare manifestation of common urinary aerobic pathogens and is generally seen in patients with diabetes mellitus or underlying urinary tract obstruction. 2 The diagnosis is facilitated by the roentgenographic demonstration of a pneumonephrogram of the involved kidney. 3 Recently we treated such a patient with striking roentgenographic findings.
gram-negative bacteria. On the roentgenogram of the abdomen the right renal shadow was not visible but the left kidney and ureter were outlined by gas, which also was observed within the kidney parenchyma (see figure). The patient was treated with supplemental oxygen, hypoosmolar intravenous fluids, sodium bicarbonate, intravenous regular insulin and hydrocortisone. After blood and urine cultures were obtained cephalothin and gentamicin were started. The hypotension failed to respond to the fluid admin-
CASE REPORT
An 81-year-old woman with an adult onset of diabetes mellitus was referred to the hospital because of hypotension and coma. She had been in good health despite diabetes, which was easily controlled by diet alone. Anorexia developed 2 days before hospitalization and the patient became lethargic. She went into a coma and was admitted to a local hospital. Examination disclosed deep rapid respirations and hypotension. Blood sugar was 900 mg. per 100 ml. The patient received 70 units of regular insulin subcutaneously and was referred for further evaluation and care. Rectal temperature was 39.4C, blood pressure was palpable at 30 mm. mercury systolic, pulse was 60 per minute, and respirations were 36 per minute and Kussmaul in character. The patient responded only to deep pain. Examination of the fundi failed to disclose diabetic stigmas. The lungs were clear and cardiac examination was unremarkable. The abdomen was firm but not rigid and bowel sounds were absent. No masses or crepitus was noted. Costovertebral angle tenderness could not be elicited. Pelvic examination suggested a right adnexal fullness and neurological examination failed to reveal localizing signs. There was no peripheral edema. Laboratory data included hemoglobin 10.1 gm. per 100 ml., hematocrit 29 per cent, white blood count 2,100 with a normal differential, sodium 122 mEq. per 1., potassium 5.3 mEq. per 1., chloride 84 mEq. per 1., carbon dioxide 12 mEq. per 1., blood sugar 1,110 mg. per 100 ml., blood urea nitrogen 77 mg. per 100 ml. and plasma creatinine 6.2 mg. per 100 ml. The serum osmolality by freezing point depression was 362 mOsm. per kg. water. Arterial blood gases, with an inspired oxygen concentration of 28 per cent, were oxygen pressure 99 mm. per Hg, carbon dioxide pressure 64 mm. per Hg and pH 6.98. No serum acetone was detected. A lumbar puncture revealed only an elevated spinal fluid glucose. The urinalysis displayed specific gravity 1.020, 3 plus protein, 3 plus glucose and 1 plus ketones. Examination of the urinary sediment revealed 20 to 30 white cells per high power field, occasional red cells and many Accepted for publication October 24, 1975. * Research fellow supported by grants from the National Kidney Foundation and the Kidney Foundation of Indiana.
604
Striking left pneumonephrogram is visible as well as intraureteral and perirenal gas.
605
ElviPEYSElAATOUS PYELON3FHRITIS
istration or to infusions of intravenous hydrochloride. The died 5 hours after hospitalization. Blood and urine cultures subsequently yielded Klebsiella pneumoniae. Postmortem examination revealed acute pyelonephritis of the left kidney, chronic pyelonephritis of the right kidney, thrombosis of the left renal vein and old rheumatic heart disease. There was no evidence of obstruction of either collecting system. DISCUSSION
Fortunately, emphysematous pyelonephritis is a rare curiosity. Costas reviewed 31 cases in the literature as of 1972 and added 3 of his own. 4 He found that the disease was more common in older women. Eighty per cent of the patients were diabetic, a quarter of whom had urinary tract obstruction. Forty per cent of the non-obstructed diabetics died, whereas 71 per cent of the obstructed diabetics suffered a fatal outcome. However, of the non-diabetic obstructed patients only 1 died. Escherichia coli was the offending organism in two-thirds of the patients. Klebsiella pneumoniae was isolated in only 4 patients. 4 The pathogenesis of emphysematous pyelonephritis is poorly understood. Since the entity is much more common in diabetic patients Schainuck and associates have postulated that the high tissue glucose levels may provide a substate for organisms that are able to produce carbon dioxide by fermentation of sugar. 1 Furthermore, these authors indicate that emphysematous pyelonephritis is a severe necrotizing infection occurring in patients with local impaired tissue and vascular response. Therefore, this condition should be regarded
as a of a severe infectious process rather than a distinct clinical entity. Patients with emphysematous pyelonephritis require prompt and vigorous intravenous antibiotic therapy for septicemia as well as management of electrolyte imbalance, shock and hyperglycemia if present. Relief of obstruction by means of diverting ureter al catheters is indicated.'· 6 Some authors have suggested that since infarction and necrosis of the involved kidney are frequently present, removal of the offending organ may be the best method of improving prognosis. 7 However, the not infrequent occurrence of contralateral involvement and the poor general condition of these patients would seem to dictate considerable caution, especially with respect to the timing of any operative intervention. 8 REFERENCES
l. Schainuck, L. I., Fouty, R. and Cutler, R. E.: Emphysematous
2. 3.
4. 5. 6. 7. 8.
pyelonephritis. A new case and review of previous observations. Amer. J. Med., 44: 134, 1968. Stokes, J. B., Jr.: Emphysematous pyelonephritis. ,J. Urol., 96: 6, 1966. Hartman, G. W.: Non-tuberculous infections of the genitourinary tract. In: Clinical Urography, 3rd ed. Edited by J. L. Emmett and D. M. Witten. Philadelphia: W. B. Saunders Co., p. 787, 1971. Costas, S.: Renal and perirenal emphysema. Brit. J. Urol., 44: 311, 1972. Kandzari, S. J. and Milam, D. F.: Renal emphysema. J. Urol., 106: 797, 1971. Klein, D. E., Mahoney, S. A., Youngen, R. and Schneider, D. H.: Renal emphysema. J. Urol., 95: 625, 1966. Banks, D. E., Jr., Persky, L. and Mahoney, S. A.: Renal emphysema. J. Urol., 102: 390, 1969. Schultz, E. H., Jr. and Klorfein, E. H.: Emphysematous pyelonephritis. J. Urol., 87: 762, 1962.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
EMPHYSEMATOUS PYELONEPHRITIS STEPHEN D. MCMURRAY,* FRJEl])RJCH C. LUFT, DOUGLAS R. MAXWELL
AND
STUART A. KLEIT
From the Renal Section, Department of Medicine, Indiana University School of Medicine and the Medicine Services, Indiana University and Veterans Administration Hospitals, Indianapolis, Indiana
ABSTRACT
Emphysematous pyelonephritis is a rare complication of urinary tract infection and generally occurs in patients with diabetes mellitus or urinary tract obstruction. We recently treated an 81-year-old diabetic woman with Klebsiella pneumoniae urinary tract infection and septicemia whose abdominal roentgenogram demonstrated a striking left pneumonephrogram as well as intraureteral and perirenal gas. The patient died despite intensive therapeutic efforts. Unfortunately, the prognosis for this severe necrotizing infection process remains unfavorable. The spontaneous generation of gas within and around the substance of the kidney is termed emphysematous pyelonephritis. 1 This clinical entity is a rare manifestation of common urinary aerobic pathogens and is generally seen in patients with diabetes mellitus or underlying urinary tract obstruction. 2 The diagnosis is facilitated by the roentgenographic demonstration of a pneumonephrogram of the involved kidney. 3 Recently we treated such a patient with striking roentgenographic findings.
gram-negative bacteria. On the roentgenogram of the abdomen the right renal shadow was not visible but the left kidney and ureter were outlined by gas, which also was observed within the kidney parenchyma (see figure). The patient was treated with supplemental oxygen, hypoosmolar intravenous fluids, sodium bicarbonate, intravenous regular insulin and hydrocortisone. After blood and urine cultures were obtained cephalothin and gentamicin were started. The hypotension failed to respond to the fluid admin-
CASE REPORT
An 81-year-old woman with an adult onset of diabetes mellitus was referred to the hospital because of hypotension and coma. She had been in good health despite diabetes, which was easily controlled by diet alone. Anorexia developed 2 days before hospitalization and the patient became lethargic. She went into a coma and was admitted to a local hospital. Examination disclosed deep rapid respirations and hypotension. Blood sugar was 900 mg. per 100 ml. The patient received 70 units of regular insulin subcutaneously and was referred for further evaluation and care. Rectal temperature was 39.4C, blood pressure was palpable at 30 mm. mercury systolic, pulse was 60 per minute, and respirations were 36 per minute and Kussmaul in character. The patient responded only to deep pain. Examination of the fundi failed to disclose diabetic stigmas. The lungs were clear and cardiac examination was unremarkable. The abdomen was firm but not rigid and bowel sounds were absent. No masses or crepitus was noted. Costovertebral angle tenderness could not be elicited. Pelvic examination suggested a right adnexal fullness and neurological examination failed to reveal localizing signs. There was no peripheral edema. Laboratory data included hemoglobin 10.1 gm. per 100 ml., hematocrit 29 per cent, white blood count 2,100 with a normal differential, sodium 122 mEq. per 1., potassium 5.3 mEq. per 1., chloride 84 mEq. per 1., carbon dioxide 12 mEq. per 1., blood sugar 1,110 mg. per 100 ml., blood urea nitrogen 77 mg. per 100 ml. and plasma creatinine 6.2 mg. per 100 ml. The serum osmolality by freezing point depression was 362 mOsm. per kg. water. Arterial blood gases, with an inspired oxygen concentration of 28 per cent, were oxygen pressure 99 mm. per Hg, carbon dioxide pressure 64 mm. per Hg and pH 6.98. No serum acetone was detected. A lumbar puncture revealed only an elevated spinal fluid glucose. The urinalysis displayed specific gravity 1.020, 3 plus protein, 3 plus glucose and 1 plus ketones. Examination of the urinary sediment revealed 20 to 30 white cells per high power field, occasional red cells and many Accepted for publication October 24, 1975. * Research fellow supported by grants from the National Kidney Foundation and the Kidney Foundation of Indiana.
604
Striking left pneumonephrogram is visible as well as intraureteral and perirenal gas.
605
ElviPEYSElAATOUS PYELON3FHRITIS
istration or to infusions of intravenous hydrochloride. The died 5 hours after hospitalization. Blood and urine cultures subsequently yielded Klebsiella pneumoniae. Postmortem examination revealed acute pyelonephritis of the left kidney, chronic pyelonephritis of the right kidney, thrombosis of the left renal vein and old rheumatic heart disease. There was no evidence of obstruction of either collecting system. DISCUSSION
Fortunately, emphysematous pyelonephritis is a rare curiosity. Costas reviewed 31 cases in the literature as of 1972 and added 3 of his own. 4 He found that the disease was more common in older women. Eighty per cent of the patients were diabetic, a quarter of whom had urinary tract obstruction. Forty per cent of the non-obstructed diabetics died, whereas 71 per cent of the obstructed diabetics suffered a fatal outcome. However, of the non-diabetic obstructed patients only 1 died. Escherichia coli was the offending organism in two-thirds of the patients. Klebsiella pneumoniae was isolated in only 4 patients. 4 The pathogenesis of emphysematous pyelonephritis is poorly understood. Since the entity is much more common in diabetic patients Schainuck and associates have postulated that the high tissue glucose levels may provide a substate for organisms that are able to produce carbon dioxide by fermentation of sugar. 1 Furthermore, these authors indicate that emphysematous pyelonephritis is a severe necrotizing infection occurring in patients with local impaired tissue and vascular response. Therefore, this condition should be regarded
as a of a severe infectious process rather than a distinct clinical entity. Patients with emphysematous pyelonephritis require prompt and vigorous intravenous antibiotic therapy for septicemia as well as management of electrolyte imbalance, shock and hyperglycemia if present. Relief of obstruction by means of diverting ureter al catheters is indicated.'· 6 Some authors have suggested that since infarction and necrosis of the involved kidney are frequently present, removal of the offending organ may be the best method of improving prognosis. 7 However, the not infrequent occurrence of contralateral involvement and the poor general condition of these patients would seem to dictate considerable caution, especially with respect to the timing of any operative intervention. 8 REFERENCES
l. Schainuck, L. I., Fouty, R. and Cutler, R. E.: Emphysematous
2. 3.
4. 5. 6. 7. 8.
pyelonephritis. A new case and review of previous observations. Amer. J. Med., 44: 134, 1968. Stokes, J. B., Jr.: Emphysematous pyelonephritis. ,J. Urol., 96: 6, 1966. Hartman, G. W.: Non-tuberculous infections of the genitourinary tract. In: Clinical Urography, 3rd ed. Edited by J. L. Emmett and D. M. Witten. Philadelphia: W. B. Saunders Co., p. 787, 1971. Costas, S.: Renal and perirenal emphysema. Brit. J. Urol., 44: 311, 1972. Kandzari, S. J. and Milam, D. F.: Renal emphysema. J. Urol., 106: 797, 1971. Klein, D. E., Mahoney, S. A., Youngen, R. and Schneider, D. H.: Renal emphysema. J. Urol., 95: 625, 1966. Banks, D. E., Jr., Persky, L. and Mahoney, S. A.: Renal emphysema. J. Urol., 102: 390, 1969. Schultz, E. H., Jr. and Klorfein, E. H.: Emphysematous pyelonephritis. J. Urol., 87: 762, 1962.
