Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection characterized by production of intraparenchymal gas. EPN predominantly affects female diabetics and immunocompromised patients. In a three-year period 2008–2011, a total of 8 patients were admitted to our hospital. All of them were diabetics, and both males and females were equally affected. These patients showed vague symptoms at admission and frequently presented with fever, loin pain, dysuria, and pyuria necessitating urgent medical attention. EPN required radiological diagnosis. CT scan revealed bilateral EPN with urinary obstruction and hydronephrosis in 50% of patients.
Emphysematous pyelonephritis (EPN) is a life-threatening, fulminant, necrotizing upper urinary tract infection associated with gas within the kidney and/or perinephric space [
During the period 2008–2011, a total of eight diabetic patients with clinical features of EPN and computerized tomography (CT) image showing gas in renal parenchyma, collecting system or perirenal space, and no fistulous connection between urinary tract and bowel were evaluated.
All the patients were between 33 and 58 yrs. Males and females were equal in numbers. Clinical profiles and outcomes were shown in Table
Clinical profile and outcome of patients with EPN.
Patient | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
---|---|---|---|---|---|---|---|---|
Gender/age (yr) | M/54 | F/52 | M/33 | F/53 | F/55 | M/58 | M/38 | F/54 |
Duration of diabetes (yr) | 18 | 10 | 4 | 5 | 8 | 12 | 5 | 6 |
Fever | + | + | + | + | + | + | + | + |
Loin pain | + | + | + | + | + | + | + | + |
Oliguria | + | + | − | + | − | + | + | + |
Dysuria | + | + | + | + | + | + | + | + |
Serum creatinine at admission (mg/dL) | 7 | 7.7 | 2.3 | 7.8 | 2.7 | 5.8 | 3.1 | 7.4 |
Serum creatinine at discharge (mg/dL) | 3.3 | 3.24 | 1.8 | 2.6 | 1.6 | 1.7 | 1.8 | 3.2 |
Urine culture | ||||||||
Blood culture | Sterile | Sterile | Sterile | Sterile | Sterile | Sterile | Sterile | Sterile |
Laterality | Bilateral | Bilateral | Unilateral | Bilateral | Unilateral | Bilateral | Unilateral | Unilateral |
Huang et al. CT-scan staging | 4 | 4 | 3A | 4 | 1 | 4 | 2 | 2 |
Hemodialysis sessions | 4 | 4 | 0 | 3 | 0 | 4 | 0 | 4 |
Hydronephrosis | Yes | No | No | Yes | No | Yes | No | Yes |
DJ stent | Yes | No | No | Yes | No | Yes | No | Yes |
Duration of DJ stent (days) | 10 | − | − | 14 | − | 14 | − | 12 |
Recurrence of obstruction | No | − | − | No | − | No | − | No |
Antibiotics used | IME | IME | IME | Pip + Tz | Cef + Slb | IME | Cef + Slb | IME |
Duration of antibiotics (days) | 10 | 14 | 10 | 14 | 14 | 10 | 14 | 10 |
IME: Imipenem, Pip + Tz: Piperacillin + Tazobactam, Cef + Slb: Cefoperazone + Sulbactam.
(a) CT KUB showing bilateral emphysematous pyelonephritis (Class IV). (b) CT KUB showing resolution of air pockets after 10 days of treatment.
(a) CT KUB showing air pockets in right collecting system. (b) CT KUB showing air pocket in right proximal ureter.
CT KUB showing air pocket in left renal parenchyma and perinephric collection.
CT KUB showing emphysematous cystitis.
EPN is defined as a severe necrotizing renal parenchymal infection that is characterized by the bacterial production of gas within the renal parenchyma. The commonest causative organism is
In our study, all the patients were diabetics, and majority had uncontrolled blood sugars. All of them presented with fever, loin pain, dysuria, pyuria, and oliguria. Dyspnea and pedal edema are seen in 5/8, and one had altered sensorium. The causative organism was found to be
EPN requires a radiological diagnosis and CT being the definitive modality for diagnosis [
Patients with emphysematous pyelonephritis (EPN) should be treated with aggressive medical management and possibly prompt surgical intervention [
Emphysematous pyelonephritis is not uncommon. It should be suspected in every diabetic patient with urosepsis. CT is the definitive modality for diagnosing EPN. Early diagnosis and effective conservative treatment obviate the need for nephrectomy and decrease mortality.