Recurrent emphysematous pyelonephritis. A case report

[Emphysematous pyelonephritis of single kidney: review of literature about one case]

INTRODUCTION

Emphysematous pyelonephritis is a rare and severe form of acute pyelonephritis. It is defined as the presence of gas-producing bacteria in the kidney and in peri-nepheretic areas. We report a case of emphysematous pyelonephritis on a single kidney associated with urolithiasis.

OBSERVATION

A 44-year-old woman, with a history of diabetes and chronic renal failure, presented with left renal colic, anuria, fever and worsening of general state. The diagnosis of emphysematous pyelonephritis was confirmed by CT scan. The treatment was based on antibiotheray, adapted to the renal function, insulinotherapy and urine drainage by a double J stent. The evolution was favourable.

DISCUSSION

Emphysematous pyelonephritis is an uncommon infection, generally affecting female diabetic patients. CT scan is mandatory to confirm diagnosis.

CONCLUSION

Even if it is rare, emphysematous pyelonephritis is associated with a high mortality in the absence of a rapid and effective treatment.

Successful medical management of recurrent emphysematous pyelonephritis

Emphysematous pyelonephritis is characterized by infection and gas formation in the renal parenchyma. This rare disorder tends to occur more frequently in patients with diabetes mellitus and urinary tract obstruction. In this case report, we describe a nondiabetic patient with Hinman syndrome who developed recurrent emphysematous pyelonephritis that was successfully treated with antibiotics on both occasions.

Pyélonéphrite emphysémateuse : diagnostic et traitement

Emphysematous pyelonephritis is a necrotizing kidney infection characterized by the presence of gas in renal parenchyma, collecting system or perinephric tissue. This rare affection occurs almost exclusively in patients with diabetes mellitus and is due to non-anaerobic gas-producing bacteria. This life-threatening condition leads to septic shock and multiple organ failure. Diagnosis is suspected when a pyelonephritis does not respond to correct treatment, especially with altered vital signs or a diabetic patient. Computed tomography scan permits visualization of the gas and a radiologic classification with a prognostic value. Current treatment modalities are based upon repeated clinical and scanographic evaluations. In addition to systematic antibiotic therapy, percutaneous drainage is probably the first therapeutic stage in the majority of cases, but should not delay emergent rescue nephrectomy if necessary.

[Emphysematous pyelonephritis in diabetics]

Emphysematous pyelonephritis is a rare, life-threatening complication of upper urinary tract infections, characterized by the presence of gas in renal parenchyma and perirenal space. It occurs in 90% of cases in diabetic patients and E coli is the most common causative germ. The pathogenesis probably involves several factors including enhanced proliferation of microorganisms due to altered immune defences, mixed acid fermentation of glucose leading to gas production, and decreased elimination of the gas because of impaired tissue perfusion. Diagnosis is often delayed because the symptoms may be non-specific, as illustrated by the two cases we report herein. In patients with diabetes and febrile urinary tract infection, obstruction of the urinary tract should first be eliminated by echography. Then, if the infection does not rapidly respond to antimicrobial therapy, a scan should be performed. Aggressive management including correction of hemodynamics, parenteral antimicrobial therapy, and diabetes control with insulin therapy is mandatory, but a surgical procedure (nephrectomy or drainage) is almost always required.

Bilateral emphysematous pyelonephritis

In any diabetic patient being diagnosed or treated for pyelonephritis, it is important to exclude the diagnosis of emphysematous pyelonephritis, which carries a high mortality rate. The authors present an illustrative case of emphysematous pyelonephritis treated with antibiotics and emergency nephrectomy. The signs, symptoms, pathophysiology, diagnosis, and treatment of emphysematous pyelonephritis are discussed.