Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature

A case report on the atypical presentation of Renal tuberculosis as emphysematous pyelonephritis

INTRODUCTION AND IMPORTANCE

Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection, that causes gas to build up in the collecting system, renal parenchyma, and perirenal tissues (Mahmood et al., 2020). Uncontrolled diabetes mellitus and urinary tract obstruction are the two main risk factors. We report the second case report of tuberculosis as a causative pathogen of EPN.

CASE PRESENTATION

In this case report, a 60-year-old lady with poorly controlled type 2 diabetes was admitted to the emergency room due to left flank pain, a low-grade temperature, nausea, and vomiting. Emphysematous Pyelonephritis was diagnosed based on gas seen in the renal parenchyma on a CECT scan (EPN). She underwent conservative management, including the insertion of a nephrostomy tube and antibiotics. There is no growth detected in the nephrostomy drain's culture. She underwent a simple nephrectomy after deciding that she had not improved clinically after receiving conservative treatment. A biopsy of the specimen revealed a tuberculosis abscess. She received the proper care and made clinical progress over the course of a six-month anti-TB medication regimen.

CLINICAL DISCUSSION

The majority of EPN patients are female (2:1) and diabetic (90 %) with a mean age of presentation of 55 years (El Rahman et al., 2011). The preferred method of diagnosis for EPN is CT (El Rahman et al., 2011). E. coli, Klebsiella, and Pseudomonas were the most prevalent species in many of the reported cases (Khaira et al., 2009). In contrast to prior investigations, we discovered a case of EPN caused by tuberculosis invasion.

CONCLUSION

An essential lesson to learn from such cases is the importance of considering genitourinary tuberculosis when emphysematous pyelonephritis does not improve with conservative treatment, especially in areas with a high tuberculosis endemicity.

Conservative Management of a COVID-19-positive Patient With Emphysematous Pyelonephritis: A Case Report

Herein, we present a case of emphysematous pyelonephritis with septic shock that was treated conservatively. A 44-year-old woman with diabetes mellitus presented to the emergency department with acute abdominal discomfort. Clinical examination revealed that the patient was conscious but vitally unstable. Therefore, the patient required inotropic support. A computed tomography scan revealed gas in the left kidney, suggestive of emphysematous pyelonephritis. Subsequently, the patient was treated conservatively and stabilized with broad-spectrum antibiotics, strict blood glucose management, and drainage.

Hung up with a Huang class 4: our experience with bilateral emphysematous pyelonephritis in a COVID 19 patient

The COVID 19 pandemic has forced us to rethink our management strategies for surgical diseases. Patients with COVID 19 have increased risk of morbidity and mortality after surgical intervention. Emphysematous pyelonephritis (EPN) is often seen in diabetics and can be a life threatening condition. All patients require immediate treatment with antibiotics and close monitoring. Bilateral EPN is a rare entity seen in less than 10% of patients. We present a case of bilateral EPN in a COVID positive patient which was successfully managed conservatively. A 70 year old hypertensive female, presented to us with fever, breathlessness, loss of appetite, generalised weakness requiring oxygen supplementation & was diagnosed with COVID 19. Bilateral EPN (Grade 4) with perinephric collections was found on evaluation for acute kidney injury. She underwent bilateral pig tail insertion followed by bilateral DJ stenting after stabilization. She recovered dramatically, blood parameters improved and was discharged. At 1 year of follow up, patient was doing well. In the present COVID-19 pandemic where case selection for surgical intervention is crucial, we would like to highlight how a conservative approach for even Class 4 EPN is feasible after weighing the risks and benefits of the same. Patients can be spared the immediate morbidity and mortality risks due to surgical intervention during COVID 19 infection. Triaging surgical intervention can also help in better utilization of critical care facilities and man power, both invaluable in the ongoing crisis.

Hyperglycaemic crisis secondary to emphysematous pyelonephritis

A 49-year-old woman presented to the emergency department acutely unwell. Initial investigations revealed hyperglycaemia, ketosis and an acute kidney injury precipitated by urosepsis. She was found to have a new diagnosis of diabetes mellitus (type 2) with a glycated haemoglobin (HbA1c) of 156 mmol/mol. CT imaging of the abdomen and pelvis revealed unilateral emphysematous pyelonephritis (EPN), radiologically classified as stage 3 severity with gas extending beyond the renal collecting system. Escherichia coli was grown on blood and urine cultures. This was sensitive to second-generation cephalosporin cefuroxime. The patient was managed with fluid resuscitation, intravenous antibiotics and renal system decompression with urinary catheter insertion. She was commenced on an intravenous insulin infusion for hyperglycaemic crisis. This case illustrates a rare presentation of hyperglycaemic crisis precipitated by EPN in a patient without a previously known diagnosis of diabetes, successfully treated with medical management alone. Close clinical and radiological follow-up was arranged to monitor the need for future nephrectomy.

Bilateral emphysematous pyelonephritis cured by antibiotics alone in a black African woman

A 78-year-old black woman with a 10-year history of diabetes mellitus was admitted to the intensive care unit. Upon admission, she presented with chills, nausea, and left flank pain. The presence of hyperglycemia (fasting blood glucose, 19.7 mmol/L) and an altered consciousness required immediate treatment with insulin analog. Laboratory investigations and enhanced computed tomography scan led to the diagnosis of bilateral emphysematous pyelonephritis (EPN). The patient responded well to conservative treatment with antibiotics, and was finally discharged after 22 days when the computed tomography scan showed resolution of all the pockets of air. This case and associated literature review of 25 previously reported cases of bilateral EPN show the changing trend of EPN management from emergency nephrectomy toward conservative treatment with potent antibiotics and/or percutaneous drainage, and has been associated with higher survival rates compared to emergency nephrectomy.

Emphysematous Pyelonephritis in Children

Emphysematous pyelonephritis is a severe necrotizing infection of the kidneys characterized by gas formation within the parenchyma, the collecting system or the perinephric tissue. To our knowledge, there have only been 4 cases of this condition reported in children. We report 2 additional cases in children managed at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

Emphysematous pyelonephritis: Is nephrectomy warranted?

INTRODUCTION

Emphysematous pyelonephritis (EPN) is associated with high mortality rate, up to 25%. There is still conflicting reports regarding the most appropriate management, conservative versus nephrectomy.

OBJECTIVE

To describe the outcome of patients with EPN.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with EPN by computed tomography from three tertiary institutes in Jeddah, Saudi Arabia. Type of management was classified as conservative and surgical. The conservative includes medical and minimally invasive procedures, such as percutaneous drainage and nephrostomy. The surgical which is nephrectomy. The outcome observed was preservation of the kidney function or patient's life.

RESULTS

A total of 10 patients were included (9 females and 1 male), median age was 55 years and 63% were diabetic. The most common presentation was flank pain (100%), fever (75%), and vomiting (63%). The most common organism isolated was Escherichia coli. Nephrectomy was not associated with increased survival rate, while conservative management was associated with a good outcome, less morbidity (not dialysis-dependent).

CONCLUSION

Nephrectomy was not associated with high survival rate. Patients managed conservatively had a better overall performance and better survival. This study will add to other studies, which are encouraging conservative management.

Bilateral Emphysematous Pyelonephritis with Hepatic Portal Venous Gas: Case Report

Emphysematous pyelonephritis is a rare life-threatening condition caused by a severe acute necrotising infection of the renal parenchyma and its perinephric tissues, and it is commonly seen in diabetic patients. There is a rare association between emphysematous pyelonephritis and hepatic portal venous gas. Hepatic portal venous gas is an uncommon radiological finding, which implies a significant underlying abdominal disease. The management of emphysematous pyelonephritis has evolved from prompt nephrectomy to medical therapy. In the present report, we present a case of a diabetic woman diagnosed with bilateral emphysematous pyelonephritis with hepatic portal venous gas that was successfully managed medically despite the presence of poor prognostic factors, such as acute renal failure and thrombocytopenia.

Successful medical treatment of emphysematous pyelonephritis in chronic hemodialysis

Emphysematous pyelonephritis (EPN) is a life-threatening renal infection caused by gas-producing bacteria and fungi. It usually occurs in patients with diabetes and patients with urinary tract obstruction. A combination of systemic antibiotics, percutaneous catheter drainage, or open nephrectomy is typically required to achieve cure. Because of grim prognosis, resorting to interventional methods is frequently inevitable. We report the case of a 77-year-old woman with diabetes and end-stage renal disease on chronic hemodialysis that presented with fever and left flank pain. A bubbly gas pattern inside the left kidney was demonstrated on abdominal computed tomography scan and blood cultures grew Escherichia coli. She was successfully treated solely with systemic antibiotics. This highlights the fact that prompt recognition of imaging findings associated with benign prognosis is essential for a favorable outcome. It allows for an effective management avoiding high-risk interventions, especially in frail patients with multiple comorbidities. Finally, we review all published cases of EPN in chronic dialysis patients.

Fever with abdominal pain and diabetes - Is it Emphysematous Pyelonephritis?

Emphysematous pyelonephritis (EPN) is a rare, severe infection of renal parenchyma presenting commonly with fever and flank pain and presence of gas in the renal and/or peri-renal space. EPN can be life threatening if not diagnosed and treated promptly. Air shadows in the renal or peri-renal region on imaging studies of the abdomen are diagnostic features of EPN. However, computed tomography (CT) scan of the abdomen is better than ultrasound for diagnostic classification, prognosis, and treatment options. We treated a young female with uncontrolled type II diabetes mellitus who had severe abdominal and back pain with fever. The CT scan confirmed the diagnosis of EPN. The conservative treatment itself was effective in complete resolution of the disease even though patient had severe type of EPN.