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CASE REPORT |
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Year : 2013 | Volume
: 6
| Issue : 4 | Page : 447-449 |
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Extensive bilateral emphysematous pyelonephritis with calculi managed conservatively with antibiotics and DJ stent
Madhulika Mahashabde, Sukanya Kumar, Kapil Borawake
Department of Medicine, Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, India
Date of Web Publication | 17-Sep-2013 |
Correspondence Address: Madhulika Mahashabde Department of Medicine, Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.118283
Emphysematous pyelonephritis is a life threatening, necrotizing upper urinary tract infection associated with gas within the kidney and/or perinephric space. To prevent mortality from this fulminant infection, early diagnosis is essential. CT scan should be done early in patients with suspected emphysematous pyelonephritis. Here, we present a case of Type II Diabetes Mellitus complicated with left obstructive ureteric calculi, diagnosed on CT scan to have extensive bilateral emphysematous pyelonephritis of class 4. We treated conservatively with antibiotics and DJ stent. The patient responded and a repeat CT scan was done after 4 weeks which showed no evidence of emphysematous pyelonephritis. Keywords: Bilateral emphysematous pyelonephritis, DJ stent, ureteric calculus
How to cite this article: Mahashabde M, Kumar S, Borawake K. Extensive bilateral emphysematous pyelonephritis with calculi managed conservatively with antibiotics and DJ stent. Med J DY Patil Univ 2013;6:447-9 |
Introduction | | |
Emphysematous pyelonephritis is a rare acute necrotizing infection. In most cases, kidney is involved unilaterally but in 10% of cases the condition is bilateral. [1] Conventional treatment is surgical management with nephrectomy. This had its own drawback-possibly of making the patient anephric and dependence on dialysis. With advancement in urology, we have an alternate treatment option of percutaneous drainage of the abscess [2] and /or stent drainage. [3] These along with good antibiotic coverage lead to increased renal salvage even in patients with bilateral emphysematous nephritis. Nephrectomy should be reserved for patients who do not respond to conservative management. Any precipitating factors for development of emphysematous pyelonephritis like urinary calculus should be managed promptly.
Here, we report a Type II Diabetes Mellitus patient with left obstructive ureteric calculi who developed bilateral emphysematous pyelonepritis and was successfully managed by conservative management with antibiotics and DJ stent.
Case Report | | |
A 61-year-old male presented with the history of fever since 7 days which was high grade, continuous with chills, rigors and burning micturation. It was associated with abdominal pain in the left flank which was dull aching, diffuse, continuous, and non-radiating. No history of oliguria, dysuria, hematuria or breathlessness. Patient was a known case of Type II Diabetes Mellitus since 10 years on irregular treatment.
On examination, patient was febrile - 101 F, heart rate - 120 bpm, regular, BP - 150/90 mmHg right supine, RR - 20 cpm, SpO2 - 95% on room air. Systemic examination: Per abdomen examination revealed tenderness in the left lumber region. Other systems were normal.
During the stay, patients' renal function declined with urea and creatinine rising to 116 mg/dl and 4.1 mg%, respectively. His TLC was 15,200/cumm with neutophils 83%. Urine routine suggestive of 1+ albuminuria, pus cells were 40-50 /hpf, RBCs 20-10 /hpf, and no casts. USG KUB was suggestive of bilateral renal calculus with mild right hydronephrosis, multiple hyperechoic foci in both kidneys and bladder. Further investigation showed urine culture positive for E. coli (ESBL) with colonic count > 10 5 cfu/ml and blood culture showed Methicillin Resistant Staph. Aureus (MRSA). Blood sugar level on admission was 564 mg/dl, urine ketones were negative. CT urography plain [Figure 1], [Figure 2], [Figure 3] showed air in bilateral pelvis calyces system with small non-obstructive calculi bilaterally. Left ureter and urinary bladder showed small air pockets. Left mid ureter showed 6 mm calculus with proximal hydroureter and hydronephrosis. Mild perinephric fat stranding was seen with focal hypodensity adjacent to mid pole of right kidney suggestive of pyelonephritis with perinephric extension. | Figure 1: Axial plain CT image shows air within the calyces at lower pole of left kidney (white arrow) and within the renal pelvis (grey arrow)
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| Figure 2: Black arrows point air within pelvicalyceal system. White arrow shows renal calculi in right kidney on thin axial plain CT image. Perinephric fat stranding is noted
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| Figure 3: Air within the pelvicalyceal system seen as hypodense areas on these oblique sagittal images of plain CT abdomen
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Patient was treated conservatively with antibiotics -Pipercillin/ Tazobactum and Tigecycline for 2 weeks. Later patient was shifted on Tab. Nitrofurantoin 50 mg bid for 10 more days. Proper fluid balance was maintained. Blood glucose level was controlled with regular human insulin. Later patient was posted for cystointernal urethrotomy, left ureteroscopic lithotripsy and left DJ stenting. Post surgery the patient was asymptomatic, renal function improved and maintained good gylcemic control.
Repeat CT scan was done after 4 weeks showed resolved emphysematous pyelonephritis. Fever subsided, TLC count was 10, 400 with improved renal function parameter with urea and creatinine levels reduced to 34 mg/dl and 2.2 mg%, respectively. DJ stent was removed after 6 weeks.
Discussion | | |
Emphsematous pyelonephritis is defined as a necrotizing infection of the renal parenchyma and its surrounding areas that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The clinical symptoms of emphysematous pyelonephritis are similar to those of acute pyelonephritis. More than 90% of cases occur in diabetics with poor glycemic control. Other predisposing factors include urinary tract obstruction, polycystic kidneys and end stage renal disease. Emphysematous pyelonephritis has also been reported in debilitated, alcoholic and immunocompromised patients. [4]
Escherichia More Details coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases. [5],[6] Other organisms are Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Aerobacter aerogenes, Citrobacter and rarely yeast. [7]
Two staging systems based on CT findings have been proposed for prognostic and therapeutic reasons. Wan et al. described two types [8] -Type I included patients showing parenchymal destruction with streaky or mottled gas but with no fluid collection and a mortality rate of 69%. Type II patients had renal or perirenal fluid collections that contained bubbly or loculated gas or gas within the collecting system and mortality rate of 18%.
A more detailed staging has been put forward by Haung et al., which is as follows: class 1 - gas in the collecting system; class 2 - gas in parenchyma without extension into the extrarenal space; class 3A - extension of gas to perinephric space; class 3B - extension of gas to paranephric space; and class 4 - bilateral emphysematous pyelonephritis or single kidney emphysematous pyelonephritis. [9],[10]
Based on the above radiological classification Huang and Tseng et al. [9],[10] also proposed certain therapeutic modalities - (class 1 and 2) is confronted by antibiotic treatment, combined with CT-guided percutaneous drainage. For extensive emphysematous pyelonephritis (class 3 and 4) without any signs of organ dysfunction antibiotic therapy combined with percutaneous catheter placement should be attempted. However, nephrectomy should be promptly attempted in patients with extensive emphysematous pyelonephritis and signs of organ dysfunction.
Treatment of patients with EPN comprises resuscitation, correction of any electrolyte and glucose problems, and administration of antibiotics targeting Gram-negative bacteria. Ureteric obstruction, if present, is relieved by a percutaneous nephrostomy or stent. Definitive management is by percutaneous drainage, except when there is extensive diffuse gas with renal destruction. [11] Prompt diagnostic imaging (CT) scan recommended before starting the treatment. Risk factors indicating poor prognosis include thrombocytopenia, acute renal failure, altered consciousness and shock should be evaluated.
In our patient, because of extensive bilateral renal involvement class 4 with acute renal failure, we started patient on conservative management with antibiotics and regular human insulin. Patient responded with medical management. Further for left ureteric calculus - cystointernal urethrotomy, left ureteroscopic lithotripsy was done and left DJ stent was put for 6 weeks.
Conclusion | | |
It is not necessary to do nephrectomy for every patient of emphysematous pyelonephritis. Patient can be well conserved with antibiotics, IV fluids, good glycemic control and drainage. If the patient does not respond to conservative management, nephrectomy is the definitive therapy.
References | | |
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2. | Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10 year experience. J Urol 1997~157:1569-73. [PUBMED] |
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8. | Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996;198:433-8. [PUBMED] |
9. | Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, managementprognosis, and pathogenesis. Arch Intern Med 2000;160:797-805. [PUBMED] |
10. | Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ. Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis 2005;46:432-9. [PUBMED] |
11. | Pontin AR, Barnes RD. Current management of emphysematous pyelonephritis. Nat Rev Urol 2009;6:272-9. [PUBMED] |
[Figure 1], [Figure 2], [Figure 3]
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