Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection

A case of emphysematous cystitis caused by mechanical stimulation of pelvic fracture nonunion

Emphysematous cystitis is a rare condition that develops due to tissue hyperglycemia and urinary tract infection by gas-producing bacteria. We report a case of emphysematous cystitis caused by mechanical stimulation of a pelvic fracture nonunion. An 80-year-old man was injured in a motorcycle accident and diagnosed with pelvic fracture. Seven days later, he had high fever and computed tomography (CT) revealed gas in the hematoma around the pelvic fracture and the abscess. Therefore, infection following the pelvic fracture was diagnosed. Despite multiple operations and antibiotics treatment, malformation and nonunion of the pelvis occurred. One month after starting weight bearing, emphysema of the bladder wall adjacent to the pubic fracture were found and spread throughout the bladder wall. With stopping of weight bearing, antibiotics treatment and a urinary catheter, emphysema disappeared after 2 months. It was considered that the pubic fracture fragment irritated the bladder wall due to weight bearing and emphysematous cystitis consequently developed.

A novel mortality risk score for emphysematous pyelonephritis: A multicenter study of the Global Research in the Emphysematous Pyelonephritis group

Background

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality. We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission.

Materials and methods

Patients diagnosed with EPN between 2013 and 2020 were retrospectively included. Data from 15 centers (70%) were used to develop the scoring system, and data from 7 centers (30%) were used to validate it. Univariable and multivariable logistic regression analyses were performed to identify independent factors related to mortality. Receiver operating characteristic curve analysis was performed to construct the scoring system and calculate the risk of mortality. A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points. The area under the curve was used to quantify the scoring system performance. An 8-point scoring system for the mortality risk was created (range, 0-7).

Results

In total, 570 patients were included (400 in the test group and 170 in the validation group). Independent predictors of mortality in the multivariable logistic regression were included in the scoring system: quick Sepsis-related Organ Failure Assessment score ≥2 (2 points), anemia, paranephric gas extension, leukocyte count >22,000/μL, thrombocytopenia, and hyperglycemia (1 point each). The mortality rate was <5% for scores ≤3, 83.3% for scores 6, and 100% for scores 7. The area under the curve was 0.90 (95% confidence interval, 0.84-0.95) for test and 0.91 (95% confidence interval, 0.84-0.97) for the validation group.

Conclusions

Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

Diagnostic and Management of Emphysematous Hepatitis with Emphasis on Biopathology

Emphysematous hepatitis is a rare infectious disease, which corresponds to the presence of gas in the liver, without collection and after exclusion of vascular origin. This entity belongs to the group of emphysematous infections, whose physiopathology seems to be linked to the presence of unbalanced diabetes and to bacterial fermentation, leading to the production of gas within the liver parenchyma. Very few cases of emphysematous hepatitis have been described in the literature, and most of them had a rapidly fatal course. In this manuscript, we report the case of a 59-year-old man with emphysematous hepatitis due to wild-type Klebsiella pneumoniae that was successfully managed by surgery, and we perform a review of the literature to describe the clinical and biopathological aspects of this rare hepatic disease. Our manuscript underlines the need to perform biological and histopathological sampling to better understand the pathophysiology of this rare entity. The causes and mechanisms of emphysematous hepatitis, which seem to be multiple, lead us to believe that it is a syndrome rather than a simple infectious disease.

Successful Conservative Management of Emphysematous Cystitis With Pneumoperitoneum: A Case Report and Literature Review

Emphysematous cystitis is a rare type of urinary tract infection that is characterized by the accumulation of gas within the walls and lumen of the urinary bladder. In rarer instances, pneumoperitoneum may accompany emphysematous cystitis. When pneumoperitoneum is suspected through imaging studies in patients with emphysematous cystitis, surgical abdominal exploration is frequently performed considering the possibility of bladder perforation or coexistence of intestinal perforation. We successfully managed a case of emphysematous cystitis accompanied with pneumoperitoneum conservatively. A 90-year-old woman hospitalized with a gastric ulcer developed abrupt lower abdominal pain and hematuria. Contrast-enhanced CT revealed gas within the bladder wall, which was consistent with emphysematous cystitis, and pneumoperitoneum. No obvious bowel or bladder perforation was observed in the CT scan. Regarding her high surgical risk and clinical stability, surgical abdominal exploration was not performed, and she was managed conservatively with urethral catheter placement and antibiotics. She recovered with the treatment, and CT imaging obtained on day 18 demonstrated resolution of the bladder wall emphysema and no signs of pneumoperitoneum. We performed a literature review using MEDLINE and Japana Centra Revuo Medicina Web and confirmed 13 previously reported cases of emphysematous cystitis and pneumoperitoneum. Based on the review of these 13 cases and our case, it is difficult to predict the presence of bladder perforation solely based on peritoneal signs in physical findings or ascites on CT scans. Therefore, it would be preferable to perform surgical abdominal exploration to make a definite diagnosis and select an appropriate treatment. However, the fact that at least eight out of the 10 cases managed conservatively survived suggests that there is a specific clinical entity among patients who present with emphysematous cystitis and pneumoperitoneum that can be safely managed conservatively. Further accumulation of cases and research is necessary to determine which cases can be treated conservatively.

Case report: Emphysematous cystitis due to Escherichia coli infection with the extension of gas into multiple locations in two non-diabetic dogs: a computed tomographic diagnosis and successful management

Emphysematous cystitis is an extremely rare, complicated urinary tract infection with the presence of gas in the bladder wall and lumen caused by gas-producing bacterial infections. A 7-year-old spayed female pomeranian dog was presented with a 3-day history of hematuria and pollakiuria (case 1), and a 9-year-old spayed female jindo dog was presented with a 4-day history of intermittent hematuria (case 2). Imaging modalities, including radiography, ultrasonography, and computed tomography, and bacterial culture tests were used for the diagnosis. Emphysematous cystitis due to Escherichia coli infection with the extension of gas into multiple locations was identified in both cases. Based on the results of antibiotic susceptibility testing, systemic antibiotics were initiated. Both animals had an excellent response to antibiotic treatment, and the clinical signs of the gas collection were completely resolved within ~1 month after treatment initiation. This response was sustained without recurrence in the follow-up period. This case report describes clinical details of extremely rare canine cases of emphysematous cystitis with the extension of gas into multiple locations and evaluates the clinical efficacy of antibiotic therapy.

Emphysematous hepatitis with successful treatments: A rare case report

RATIONALE

Emphysematous hepatitis (EH) is a rare and fulminant gas-forming liver infection. Only 3 patients were successfully treated. Diabetes mellitus and a history of digestive system cancer may predispose individuals to EH. Computed tomography (CT) findings support the diagnosis of EH and monitor progress.

PATIENT CONCERNS

A 48-year-old man with diabetes presented with nausea, vomiting (gastric contents) and diarrhea. Laboratory test results revealed elevated levels of inflammatory indicators and abnormal liver function. CT showed a large-scale air collection with some remaining parenchymal debris in the left lobe of the liver. Remarkably, no fluid was observed inside the lesion.

DIAGNOSE

The abdominal CT features and laboratory examination results rationalized the diagnosis of EH.

INTERVENTIONS AND OUTCOMES

The patient finally recovered from this severe disease through a series of effective treatments, including strict glucose control, sensitive antibiotic therapy, and subsequent percutaneous drainage.

LESSONS

EH generally deteriorates rapidly and eventually leads to death. This case will raise awareness of the rare and severe disease, strengthen diagnostic capacities, and provide advice to treat it.

Emphysematous cystitis: an incidental finding with varying outcomes

Emphysematous cystitis (EC) is a rare severe urinary tract infection characterised by pockets of air in and around the urinary bladder wall caused by gas-forming organisms. Common predisposing factors are chronic infection, immunosuppression, diabetes and neurogenic bladder. The presentation may vary from mild illness to severe life-threatening cystitis. We report two cases of incidental detection of EC diagnosed on imaging for the evaluation of unrelated symptoms. Although asymptomatic, this lethal disease still warrants prompt recognition and treatment with broad-spectrum antibiotics and urinary bladder drainage to prevent severe morbidity and mortality.

Percutaneous drainage for non-operative management of emphysematous pyelonephritis: Clinical characteristics and predictors of success

Emphysematous pyelonephritis (EPN) is a necrotizing renal infection that can rapidly progress without urgent intervention. The purpose of this study was to evaluate the safety and efficacy of percutaneous nephrostomy (PN) in the management of EPN, as well as the relationship of outcomes with initial classification by the Huang-Tseng classification system and other prognostic factors such as thrombocytopenia. A retrospective review of medical records revealed seven patients with EPN treated with PN. Thirty-day survival rate was 86%, with the only mortality due to an arrhythmia secondary to underlying cardiomyopathy rather than a complication from EPN or PN. A single nephrostomy procedure served as definitive treatment in 3 patients (43%). Reintervention due to recurrence of EPN symptoms was required in 4 patients (57%), all of which initially presented with Class 3 disease or higher. Two of these four patients required nephrectomy, while the other two were successfully managed with a second drainage procedure without further recurrence of symptoms. PN appears to be a safe and generally effective management option for EPN, especially in patients who are considered poor surgical candidates. PN may serve as definitive treatment in hemodynamically stable patients with lower class of disease. In patients with higher class of disease, PN may be definitive treatment in patients who lack additional risk factors such as thrombocytopenia or serve as an effective bridge to nephrectomy.

Emphysematous Pyelonephritis Complicated With Hyperglycemic Hyperosmolar State and Sepsis: A Case Report and Literature Review

Emphysematous pyelonephritis (EPN) is an acute life-threatening necrotizing infection of the renal parenchyma and perirenal tissues. There are multiple treatment strategies for EPN depending on the initial classification; over the last three decades, the treatment approach has favored kidney sparing strategies and the use of nephrectomy only as salvage therapy. We report a case involving a patient with unilateral emphysematous pyelonephritis complicated with hyperglycemic hyperosmolar state (HHS), sepsis, and multiple risk factors associated with poor prognosis who was successfully treated with conservative management sparing nephrectomy. This case report aims to create awareness among clinicians that even in the presence of multiple risk factors for poor prognosis, conservative management should be considered before nephrectomy.

Predictive factors for mortality and intensive care unit admission in patients with emphysematous pyelonephritis: 5-year experience in a tertiary care hospital

INTRODUCTION AND OBJECTIVES

Emphysematous pyelonephritis is a life-threatening infection of the kidney and surrounding tissues associated with a high mortality rate. The aim of this study was to determine predictive factors for mortality and intensive care unit admission in patients with emphysematous pyelonephritis, and to propose a therapeutic algorithm based on current literature and our experience.

METHODS

A retrospective study was done including patients with emphysematous pyelonephritis in a single center in the north of Mexico from 2011 to 2016. Demographic, clinical, microbiological and biochemical parameters, therapeutic management, and outcomes were assessed. Factors associated with admission to intensive care unit and mortality were determined. Comparison was assessed using X² test for categorical variables, and T-test for numerical variables. Univariate and multivariate logistic regression analyses were performed. Statistical significance was set at P < .05.

RESULTS

A total of 63 patients were included, of which 55 (87.3%) were females, with a mean age of 55.5 ± 12.2 years. The most common comorbidities were diabetes and hypertension. Escherichia coli was the most common isolated microorganism (51.7%) and extended-spectrum beta-lactamase-producing agents were reported in 31.7%. Conservative therapy was provided to 38.7%, double J stent 42.9%, open/percutaneous drainage 12.7%, and nephrectomy 25.3%. Overall mortality and intensive care admission were 20.6% and 36.5%, respectively. In the multivariate analysis, hemodynamic instability (P = .005), qSOFA ≥ 2 (P = .003), hypoalbuminemia (P = .02), and early nephrectomy (P = .002) were associated with intensive care admission. Huang scale 4 (P = .006) and early nephrectomy (P = .001) were associated to mortality.

CONCLUSIONS

Emphysematous pyelonephritis is a life-threatening disease and evidence of management is based in small case series due to the low incidence of this condition. Hemodynamic instability, hypoalbuminemia, qSOFA ≥ 2, Huang scale ≥3, and early nephrectomy are associated with poor prognosis.

Identification of Microorganisms Using an EWOD System

Among the advantages of an electrowetting-on-dielectric (EWOD) chip are its uncomplicated fabrication and low cost; one of its greatest strengths that might be applied in the field of biomedical technology is that it can accurately control volume and reduces the amount of samples and reagents. We present an EWOD for the biochemical identification of microorganisms, which is required to confirm the source of microbial contamination or quality inspection of product-added bacteria, etc. The traditional kit we used existed in the market; the detection results are judged by the pattern of color change after incubation. After a preliminary study, we confirmed that an image-processing tool (ImageJ) provides a suitable method of analysis, and that, when the concentration of the sugar reagent is 38 µg/µL, the best operating parameters for the EWOD chip in silicone oil are 40 V and 1.5 kHz. Additionally, we completed the biochemical identification of five bacterial species on the EWOD chip at the required concentration of the kit. Next, we found a decreased duration of reaction and that the least number of bacteria that were identifiable on the chip lies between 100 and 1000 CFU per droplet. Because the number of bacteria required on the chip is much smaller than for the kit, we tested whether a single colony can be used for identification, which provided a positive result. Finally, we designed an experimental flow to simulate an actual sample in an unclean environment, in which we divided the various processed samples into four groups to conduct experiments on the chip.

Emphysematous Cystitis in a Patient Receiving Cyclophosphamide

Emphysematous cystitis (EC) is a form of complicated urinary tract infection (UTI) well described in patients with diabetes. Other known risk factors include urinary tract obstruction, older age, and female gender. This case describes a patient who developed emphysematous cystitis while receiving induction therapy with intravenous cyclophosphamide to treat antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis that presented with rapidly progressive glomerulonephritis (RPGN). The association between cyclophosphamide therapy and emphysematous cystitis has only been reported twice in literature.

A Prospective study of Emphysematous Pyelonephritis in Patients with Type 2 Diabetes

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma. There is a lack of studies on follow up of EPN patients. The study aimed to explore the effect of EPN in patients with type 2 diabetes (T2D) on glycemic and renal parameters on follow up, and factors suggesting the failure of medical treatment.

METHODS

This was a hospital-based prospective study done over a period of 3 years on newly diagnosed consecutive 20 patients of emphysematous pyelonephritis (EPN) with T2D. Study analyzed the clinical, laboratory, radiological, microbiological findings, complications, treatment modality, and outcome. All patients were followed up for 6 months with respect to the number of urinary tract infections (UTIs), glycemic control, and renal parameters.

RESULTS

Most of the patients were postmenopausal females with longer duration of diabetes and complicated by triopathy. Fever and renal angle tenderness were the most common clinical finding. The majority of our patients 12 (60%) had EPN (class 1 and 2). Severe hyperglycemia was present in 19 (95%), hyperosmolar hyperglycemic state (HHS) in 5 (25%), diabetic ketoacidosis (DKA) in 3 (15%), and acute kidney injury (AKI) in 15 (75%). Bacteriuria was present in 90% and bacteremia in 30%. E. coli was the most common organism isolated (80%). The survival rate was 90%, with failure of medical treatment in 30%. Renal obstruction and worsening azotemia predicted the failure of medical management. The significant number (11, 55%) of patients developed recurrent UTI on follow up. Factors that increased the risk of recurrent UTI in EPN were chronic kidney disease, poor glycemia, and renal obstruction. The recurrent UTI patients had significantly higher glycosylated hemoglobin A1c (HbA1c) at follow up than at baseline, but renal parameters did not differ.

CONCLUSIONS

We recommend early aggressive medical treatment of EPN. Altered sensorium, renal obstruction, and deteriorating renal function may suggest the failure of medical treatment.

An unusual cause of free air in the abdomen: emphysematous cystitis with bladder diverticulum perforation

A 64-year-old male, with a history of chronic urinary outflow obstruction secondary to benign prostatic hyperplasia, presented with haematuria and urinary retention following spontaneous removal of his long-term catheter. The patient was septic on admission and a CT examination of the abdomen and pelvis showed an acutely inflamed urinary bladder diverticulum and extensive intra-abdominal free air. The patient was treated medically for emphysematous cystitis centred on a perforated bladder diverticulum, which was thought to be caused by the underlying infectious/inflammatory process. Alternative aetiologies for free air in the abdomen such a traumatic bladder perforation and gastrointestinal perforation were considered and excluded. The patient responded well to medical management and was discharged after an 11 day in-patient stay.

What is the prognosis of emphysematous pyelonephritis associated with extended-spectrum beta-lactamases producing microorganisms?

Objective

To describe the microbiological characteristics in emphysematous pyelonephritis (EPN), demonstrate the frequency of extended-spectrum beta-lactamase (ESBL) microorganisms, and determine if these microorganisms are associated with the prognosis of patients with EPN.

Methods

We conducted a retrospective study in patients with a diagnosis of EPN in a tertiary care hospital of the northeast region of Mexico during the period from January 2011 to January 2016. Clinical variables were analyzed to determine association with the presence of ESBL-producing microorganisms. Statistical significance was set with p<0.05.

Results

A total of 63 patients were included; 55 (87.3%) of them were females, with a median age of 55 (interquartile range: 45–65) years. Conservative management was indicated in 38.1%; 42.9% were treated with ureteral stent; 12.7% with open or percutaneous drainage; 15.8% with early nephrectomy; and 9.5% with delayed nephrectomy. Reported mortality was 13 (20.6%) cases; 23 (36.5%) cases required admission to the intensive care unit. The most frequent microorganism isolated was Escherichia coli (n=34, 53.9%). ESBL microorganisms were found in 31.7% of the population. No significant association of ESBL was found with admission to the intensive care unit, or with increased mortality.

Conclusions

To our knowledge, this is the first study that evaluates ESBL microorganisms as a prognostic factor in EPN. Risk factors associated with a poor prognosis in patients with EPN have been described. The microbiological factors, specifically ESBL-producing bacteria, do not seem to influence in the prognosis of these patients.

The role of early diagnosis of emphysematous cystitis: A case report and literature review

Emphysematous cystitis (EC) is a rare entity caused by bacteria, which produce gas filled cysts in the bladder wall. We present a case of EC in a 72-year-old woman admitted to Vascular Surgery Department because of diabetic foot syndrome. During the hospital stay, the patient's general condition deteriorated. CT established EC diagnosis. Surgical treatment was inevitable. Salvage cystectomy was performed. Despite macroscopic removal of necrotic tissues, the condition of the patient didn't improve, 75 days past diagnosis of EC she died due to the multi-organ failure. Prompt diagnosis provided by imaging plays a key role in the treatment of EC.

Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy

Introduction

Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN.

Materials and Methods

We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality.

Results

The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%.

Conclusion

Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.

Acute Renal Infection in Adult, Part 2: Emphysematous Urinary Tract Infection—What the Radiologist Needs to Know

Renal emphysema, as described by Kelly and MacCallum in 1898, refers to the spontaneous generation of gas within the renal parenchyma and surrounding tissues. Since its initial description, it has become apparent that the spectrum of radiologically visible renal and perirenal gas includes three distinct clinical entities: (1) emphysematous pyelonephritis, a necrotizing infection associated with gas formation in the renal parenchyma, (2) emphysematous pyelitis, in which gas is confined to the renal pelvis and calyces, and (3) gas-forming perinephric abscess. In this article, we will review gas-forming infections of the urinary system in terms of radiological features, clinical manifestations, predisposing factors, and appropriate management guidelines.

Simultaneous Diagnosis of Emphysematous Osteomyelitis and Emphysematous Pyelonephritis in a Diabetic Patient

BACKGROUND Emphysematous osteomyelitis of the spine is characterized by intravertebral or intraosseous air. Emphysematous pyelonephritis (EP) is the infection of the renal parenchyma and perirenal tissues caused by gas forming microorganisms and thus is characterized by gas formation. Prompt diagnosis and initiation of necessary treatment is crucial, as both entities are associated with high mortality rates. CASE REPORT A 57-year-old female with uncontrolled hyperglycemia presented to the emergency department with history of sudden onset of weakness, nausea, vomiting and diarrhea for 3 days and with a fall on the same level the previous day. Laboratory examinations revealed leukocytosis, lymphopenia, thrombocytopenia, deteriorated renal function, and hyperglycemic hyperosmolar non-ketotic state. She was placed on aggressive intravenous hydration and insulin infusion pump. Due to the deterioration of her medical condition, she underwent abdominal and pelvic CT scanning that revealed emphysematous osteomyelitis of the spine and emphysematous pyelonephritis. Despite vigorous fluid resuscitation and systemic broad-spectrum antibiotic therapy, the patient's condition deteriorated further and eventually led to death within 48 h. CONCLUSIONS This case of fatal emphysematous osteomyelitis of the spine and EP serves as a significant reminder of those rare life-threatening entities, which affect patients with comorbidities, such as diabetes mellitus and other etiologies causing immunosuppression. The aim of the present case report is to highlight the importance and contribution of computed tomography in diagnosing these conditions and to emphasize the rare coexistence of these 2 emphysematous entities.

Gas-Forming Liver Abscess versus Emphysematous Hepatitis: A Radiologic Diagnostic Dilemma-A Case Report and Review of the Literature

A 38-year-old diabetic woman, with history of cholecystectomy and ventral hernia repair, was hospitalized due to sudden-onset abdominal pain and fever. Computed tomography revealed a mixed collection containing necrotic debris and emphysematous change in the left lobe of the liver mainly in segments II and III. These radiological findings suggested emphysematous hepatitis (EH). The patient's condition deteriorated rapidly, and she was rushed to the operating room for urgent exploratory laparotomy where debridement was performed. Intraoperatively the patient was found to have an abscess with incomplete capsule concurrent with hepatic necrosis suggesting the co-occurrence of abscess and EH. The patient survived and was discharged after 13 days. Relevant literature was reviewed, and to the best of our knowledge, EH is an extremely rare entity with limited data regarding its pathogenesis, causative organisms, and management. EH is a rapidly invasive disease process that can be fatal if appropriate therapeutic intervention is delayed. Initial presentations are usually subtle, thus high clinical and radiological suspicion is required for early diagnosis and management to decrease associated mortality and morbidity. We hence report the first successfully treated case of EH with review of the literature.

Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes?

Objective:

The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients.

Materials and Methods:

The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed.

Results:

The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%.

Conclusion:

Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.

A Case of Emphysematous Cystitis

Emphysematous cystitis (EC) is an uncommon but potentially life-threatening urinary tract infection. Diagnostic difficulty exists because of the variable presentations. We report the case of a 73-year-old woman who presented with diarrhoea and malaise, and emphysematous cystitis was revealed on the abdominal X-ray. As she was treated for EC, the diarrhoea and the radiographic abnormalities of EC also resolved. The evaluation and management of this complicated urinary tract infection are discussed.

Emphysematous infections of the urinary tract - an audit of 20 patients with review of literature

Emphysematous infection of the urinary tract is a rapidly progressive, necrotizing infection which results into collection of gas and subsequent destruction of the tissues. Although very rare among general population, such necrotizing infection is common, particularly among those with compromised immune status. With the rising trend of people afflicted with diabetes mellitus globally, this fulminating infection may pose a serious threat to the medical fraternity. A high index of suspicion and abdominal CT scan usually helps to establish the diagnosis at an early stage and thereby facilitating aggressive antimicrobial therapy and percutaneous drainage where indicated. Although, extirpation of infected renal unit was the treatment of choice earlier, with the advent of modern imaging, endourological procedures and broad spectrum antibiotics, majority of such patients can be treated with minimal morbidity and mortality even with salvaging of the renal units. We present here the outcome of management of 20 cases with varied spectrum of emphysematous infection.

A Rare Case of Septic Shock Secondary to Emphysematous Hepatitis

Objective

To describe a case of emphysematous hepatitis which is a rare clinical entity, characterized by a fatal, rapidly progressive infection of the liver with a radiological appearance simulating emphysematous pyelonephritis and to help provide more data about the causative organisms and precipitating factors of this pathology.

Data Sources and Synthesis

Relevant literature was reviewed and, to the best of our knowledge, there is limited data regarding the pathogenesis, causative organisms, and management of this condition.

Conclusion

Emphysematous hepatitis is a rapidly progressive infection that can be fatal in the absence of appropriate therapeutic intervention. Initial clinical manifestations are usually subtle and thus high clinical suspicion is required for early diagnosis and management of this condition to help decrease the mortality rates.

Emphysematous pyelonephritis: A 10-year experience with 26 cases

BACKGROUND

Emphysematous pyelonephritis (EPN) is a necrotizing infection which results in gas within the renal parenchyma, collecting system, or perinephric tissue. A majority of cases occur in patients with diabetes mellitus (DM). In EPN, early aggressive medical treatment may avoid nephrectomy.

AIMS

The aim of this study was to analyze the characteristics of patients with EPN with respect to patient demographics, clinical presentation, diagnostic investigations, microbiological findings, treatment modality and outcome, and the influence of prognostic factors on the outcome.

MATERIALS AND METHODS

We reviewed the hospital records of 26 patients with EPN for clinical, laboratory, radiological, and microbiological findings, treatments given, and outcome. The severity of EPN was graded as per the Huang classification. We applied the reported prognostic factors to our patients to find out whether these factors correlated with failure of conservative treatment.

RESULTS

All the study subjects had DM and all but two of them were females. The majority of our patients (61.5%) had extensive EPN (class 3 or 4) and majority (76.9%) had two or more bad prognostic factors. Escherichia coli was the most common causative organism involved in 50% of our cases. Twenty-three (88.5%) of our patients responded to conservative treatment, two required nephrectomy, and one expired on conservative treatment.

CONCLUSIONS

In this series of patients with EPN, all had DM, nearly all were women, and E. coli was the most frequently isolated pathogen. Nearly a third of our patients had bilateral disease. Despite the presence of two or more bad prognostic factors and extensive EPN (class 3 or 4) in a majority of our patients, conservative treatment afforded a striking success rate of 88.5%. We recommend early aggressive medical treatment and suggest that nephrectomy should be considered only if patients deteriorate or do not improve on conservative treatment.

Omics-Based Comparative Transcriptional Profiling of Two Contrasting Rice Genotypes during Early Infestation by Small Brown Planthopper

The small brown planthopper (SBPH) is one of the destructive pests of rice. Although different biochemical pathways that are involved in rice responding to planthopper infestation have been documented, it is unclear which individual metabolic pathways are responsive to planthopper infestation. In this study, an omics-based comparative transcriptional profiling of two contrasting rice genotypes, an SBPH-resistant and an SBPH-susceptible rice line, was assessed for rice individual metabolic pathways responsive to SBPH infestation. When exposed to SBPH, 166 metabolic pathways were differentially regulated; of these, more than one-third of metabolic pathways displayed similar change patterns between these two contrasting rice genotypes; the difference of change pattern between these two contrasting rice genotypes mostly lies in biosynthetic pathways and the obvious difference of change pattern lies in energy metabolism pathways. Combining the Pathway Tools Omics Viewer with the web tool Venn, 21 and 6 metabolic pathways which potentially associated with SBPH resistance and susceptibility, respectively were identified. This study presents an omics-based comparative transcriptional profiling of SBPH-resistant and SBPH-susceptible rice plants during early infestation by SBPH, which will be very informative in studying rice-insect interaction. The results will provide insight into how rice plants respond to early infestation by SBPH from the biochemical pathways perspective.

Emphysematous Cystitis Found Incidentally in a Patient Undergoing Hip Arthroplasty: A Case Report

CASE

Emphysematous cystitis is a rare, complicated urinary tract infection that is potentially life-threatening if left untreated. We present the case of an eighty-one-year-old woman with left hip pain from a low-energy fall with no associated urinary symptoms. Pelvic computed tomography revealed a left femoral neck fracture and an air-fluid level in the bladder. Bipolar hemiarthroplasty was delayed for three weeks to allow for the potentially serious urinary tract infection to resolve.

CONCLUSION

Increased awareness is required for early diagnosis and treatment of asymptomatic emphysematous cystitis in a patient presenting with musculoskeletal symptoms.

[A rare cause of septic shock in diabetic: emphysematous cystitis complicated with bladder rupture]

La cystite emphysémateuse est une affection rare rencontrée principalement chez les patients diabétiques mal équilibrés. Elle se caractérise par la présence de l'air dans la paroi et/ou la lumière vesicale. La tomodensitométrie abdomino-pelvienne reste l'examen clé pour confirmer le diagnostic. Nous rapportons l'observation d'une patiente diabétique ayant présentée une cystite emphysémateuse favorisée par un diabète déséquilibré et compliquée d'une rupture vésicale intrapéritonéale avec évolution défavorable.

Management of renal cell carcinoma presenting as inflammatory renal mass

Introduction:

Renal cell carcinoma (RCC) can have a wide spectrum of clinical presentations. In the immunocompromised patient fever and an inflammatory renal mass can harbor RCC.

Materials and Methods:

We reviewed the charts of patients who were managed at our department during 1998-2008 as renal abscess or perinephric collection. Renal ultrasound and subsequently abdominal CT was done. Medical treatment in the form of antibiotics, control of diabetes and drainage was done. Percutaneous or open biopsy, pus cultures, and histopathology were used to guide therapy. With a positive biopsy radical surgery was considered, while with a negative result a follow up CT was planned.

Results:

We identified 11 patients who had high fever, a renal abscess (in 4), or a suspicious mass with perinephric collection (in 7), and were eventually diagnosed to have RCC. Mean patient age was 66 years (53-82). 8 patients had uncontrolled diabetes. Five patients had a percutaneous drainage biopsy; of those two had a positive histopathology, the other three patients had a persistent enhancing mass on follow-up CT scan. Of this group three patients underwent radical nephrectomy. Another five patients had open drainage and biopsy, four patients had very poor performance status. One patient had radical surgery without the need for biopsy.

Conclusion:

In the elderly and immunocompromised patient renal cancer may present as renal abscess or perinephric collection. Histopathology and bacteriology are the mainstay of diagnosis. If biopsy was negative, follow up should include a CT scan to exclude any residual enhancing masses.

Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess

OBJECTIVE

To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA).

METHODS

A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA).

RESULTS

The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%.

CONCLUSION

Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA.

Emphysematous cystitis due to recurrent Clostridium difficile infection

A 78-year-old woman with long-standing obstipation presented herself to the hospital with diarrhoea and progressive abdominal cramping since 2 days. Acute abdomen developed and an emergency exploratory laparotomy was indicated, which showed no signs of bowel ischaemia. After admission to the internal ward, stool Clostridium difficile PCR was tested positive. Hence the diagnosis of pseudomembranous colitis became apparent. Abdominal imaging demonstrated multiple gas foci in the wall of the bladder and extensive pseudomembranous colitis. The patient was initially treated with oral vancomycin and secondarily with metronidazole for recurrent C. difficile infection. Resolution of diarrhoea and abdominal cramping was noted on 6-week follow-up visit.

Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study

Background

Percutaneous drainage (PCD) and surgical intervention are two primary treatment options for iliopsoas abscess (IPA). However, there is currently no consensus on when to use PCD or surgical intervention, especially in patients with gas-forming IPA. This study compared the characteristics of patients with gas-forming and non-gas forming IPA and their mortality rates under different treatment modalities. An algorithm for selecting appropriate treatment for IPA patients is proposed based on our findings.

Methods

Eighty-eight IPA patients between July 2007 and February 2013 were enrolled in this retrospective study. Patients < 18 years of age or with an incomplete course of treatment were excluded. Demographic information, clinical characteristics, and outcomes of different treatment approaches were compared between gas-forming IPA and non-gas forming IPA patients.

Results

Among the 88 enrolled patients, 27 (31%) had gas-forming IPA and 61 (69%) had non-gas forming IPA. The overall intra-hospital mortality rate was 25%. The gas-forming IPA group had a higher intra-hospital mortality rate (12/27, 44.0%) than the non-gas forming IPA group (10/61, 16.4%) (P < 0.001). Only 2 of the 13 patients in the gas-forming IPA group initially accepting PCD had a good outcome (success rate = 15.4%). Three of the 11 IPA patients with failed initial PCD expired, and 8 of the 11 patients with failed initial PCD accepted salvage operation, of whom 5 survived. Seven of the 8 gas-forming IPA patients accepting primary surgical intervention survived (success rate = 87.5%). Only 1 of the 6 gas-forming IPA patients who accepted antibiotics alone, without PCD or surgical intervention, survived (success rate = 16.7%). In the non-gas forming IPA group, 23 of 61 patients initially accepted PCD, which was successful in 17 patients (73.9%). The success rate of PCD was much higher in the non-gas forming group than in the gas-forming group (P <0.01).

Conclusions

Based on the high failure rate of PCD and the high success rate of surgical intervention in our samples, we recommend early surgical intervention with appropriate antibiotic treatment for the patients with gas-forming IPA. Either PCD or primary surgical intervention is a suitable treatment for patients with non-gas forming IPA.

A case of emphysematous cystitis diagnosed by exploratory laparotomy

Emphysematous cystitis is a rare form of infection. Well known symptoms are: dysuria, urinary frequency and lower abdominal pain. We experienced a case of emphysematous cystitis presented with atypical peritoneal sign and computed tomography findings of massive intra-peritoneal fluid collection and abnormal gas appearance in pelvic space. Due to its presentation as acute abdomen, patient underwent exploratory laparotomy and the diagnosis of emphysematous cystitis was established. As far as we know, our case is the first report of emphysematous cystitis with intra-peritoneal fluid collection.

Pneumorachis associated with multiorgan infection due to Citrobacter koseri

Pneumorachis rarely occurs after spreading from a contiguous site of infection or after a traumatic event. We describe an adult patient who developed sepsis and a renal abscess due to Citrobacter koseri, and computed tomographic imaging identified gas within the entire spinal canal as well as an iliopsoas abscess. This patient recovered from pneumorachis caused by disseminated infection.

Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals

OBJECTIVE

To retrospectively review our experience of managing patients with emphysematous pyelonephritis (EPN).

METHODS

Case notes of patients with EPN were reviewed. The patients' demographic data, clinical presentation, investigation findings, treatment, and outcome were studied.

RESULTS

Twelve patients were diagnosed with EPN. Majority (66.7%) of them had diabetes mellitus. All patients had been evaluated by computed tomography (CT). Using the classification proposed by Wan et al, five patients had type 1 EPN, whereas six, two, and four patients had Huang and Tseng CT class 2, 3a, and 3b EPN, respectively. Immediate nephrectomy was performed in six patients, whereas conservative treatment was adopted in the other six. In the nephrectomy group, one patient died of disseminated sepsis after a protracted course. Conservative treatment failed in three patients, who succumbed despite salvage nephrectomy in two of them. Analysis revealed that severe hyperglycemia and radiological CT class (both Wan and Huang systems) were significant predictors of mortality from EPN.

CONCLUSION

Severe hyperglycemia and CT class of EPN are significant risk factors for death. CT is the investigation of choice for correct diagnosis of EPN. Additional intervention should be offered to EPN patients with Wan type 1 and Huang and Tseng class 3 CT features.

Unusual case of emphysematous cystitis seen on FDG PET/CT

Emphysematous cystitis is a rare condition requiring immediate aggressive medical attention. Here, we describe a very unusual case of emphysematous cystitis seen on FDG PET/CT. This finding was discovered in an 84-year-old man undergoing FDG PET/CT to monitor a known diagnosis of IgG4-related nodular sclerosis. Images revealed gas within the bladder wall and an anterior gas-filled bladder diverticulum. The patient subsequently developed sepsis with cultures revealing Escherichia coli. This case highlights the importance of recognizing this finding on varied imaging modalities, as life-threatening complications may arise from this condition.