Case presentation
A 57-year-old man with diabetes and chronic pancreatitis presented to the emergency department with a 3-day history of tachypnea and abdominal distension. His heart rate was 120 beats per minute and blood pressure was 95/55 mmHg. Physical examination revealed tenderness in the right kidney area. Initial laboratory tests showed that the white-cell count was 33.41 × 109/L (reference range, 3.5 to 9.5 109/L), serum creatinine level was 632 umol/L (reference range, 68 to 108 umol/L), and blood PH level was 7.149 (reference range, 7.35 to 7.45). Glycated hemoglobin (HbA1c) value was 12.2% (Reference value: 4.5%-6.1%). A computed tomographic (CT) scan of the abdomen showed a large area of gas in the right kidney area, ureter and bladder, a finding suggestive of emphysematous pyelonephritis (Figure A). Treatment with glycemic control, intravenous fluid, broad-spectrum antibiotics (imipenem) and continuous renal replacement therapy were initiated, and the patient was admitted to the medical intensive care unit (ICU). A percutaneous renal drain was then inserted. Blood, urine, and drainage fluid cultures grew Escherichia coli. Through continued treatment in the ICU, the patient's condition gradually improved, and he was discharged on the 31st day of hospitalization. After 4 and 8 weeks of drug treatment, repeat CT showed that the renal pneuma was gradually absorbed, and the renal parenchyma also appeared on enhanced scanning (Figure B, 4 weeks, and C, 8 weeks).
Emphysematous pyelonephritis is a rare, acute, and severe necrotizing infection of the kidney associated with a high mortality rate.
1
It is primarily caused by urinary tract infections caused by glucose-fermenting bacteria due to uncontrolled comorbidities such as diabetes mellitus, immune dysfunction, and urinary tract obstruction. E. coli is the most common causative bacteria in patients with emphysematous pyelonephritis, other common pathogenic bacteria include Klebsiella pneumoniae, Proteus mirabilis, Enterococcus, and Pseudomonas aeruginosa.2
Historically, the mortality rate of patients with emphysematous pyelonephritis has been as high as 40%. Despite improvements in antibiotics and treatment techniques, overall mortality remains high. A recent meta-analysis of 1303 patients reported an overall mortality rate of 13% in patient with emphysematous pyelonephritis. Importantly, this study found that patients treated with minimally invasive intervention, medical therapy alone and emergency nephrectomy had mortality rates of 9.9%, 14.7% and 33.3%, respectively.3
Given that studies have found that emergency nephrectomy is associated with a high risk of mortality, conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis.3
Funding
This work was supported by the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University.
Declaration of Competing Interest
We declare no competing interests.
References
- Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus.Urol Int. 2007; 78: 13-22https://doi.org/10.1159/000096929
- Emphysematous pyelonephritis: experience at a tertiary care hospital in Bangladesh.J R Coll Phys Edinburgh. Mar 2021; 51: 19-23https://doi.org/10.4997/jrcpe.2021.106
- Prevalence and risk factors of mortality in emphysematous pyelonephritis patients: a meta-analysis.World J Surg. Oct 2022; 46: 2377-2388https://doi.org/10.1007/s00268-022-06647-1
Article info
Publication history
Published online: December 23, 2022
Accepted:
December 20,
2022
Received:
September 30,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Published by Elsevier Inc. on behalf of Southern Society for Clinical Investigation.
00523-7&id=gr1.jpg){kind=link}