Abstract 15183: From Insult to Injury: A Rare Consequence of Sodium Glucose Cotransporter 2 Inhibitors

Abstract

Introduction: Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection associated with diabetes mellitus (DM), especially in older women. Patients can remain asymptomatic or present with severe sepsis and bacteremia due to E. Coli (58%) or K. pneumonia (21%). Herein, we present a unique case of recurrent life-threatening sepsis due to EPN in a male with Heart failure with reduced ejection fraction (HFrEF) and well controlled DM treated with a sodium-glucose cotransporter two inhibitor (SGLT2i). Case: A 74-year-old man with metabolic syndrome, HFrEF (EF 30%), chronic kidney disease (stage 2) who was started on empagliflozin by his cardiologist four days prior, presented to the emergency department with dizziness and fever for one day. Vitals were notable for temperature of 102.9F and blood pressure of 88/52 mmHg. The physical exam was unremarkable. His WBC was 16,000/dL, and lactate was 2.8. A sepsis workup revealed a urinalysis positive for cystitis along with a CT of the abdomen, which demonstrated evidence of acute right-sided emphysematous pyelonephritis (Fig. 01). Blood culture grew pan sensitive E coli. He was treated with IV Ceftriaxone 2g once daily for 14 days. His previous records unveiled that the patient was initially started on empagliflozin two months ago, followed by admission with EPN within ten days, after which the medication was held until its reintroduction before the current presentation. Conclusion: Emphysematous pyelonephritis as a complication of SGLTI2I use is remarkably under-reported. The median time of onset of disease from SGLT2i initiation is 45 days. The patient experienced his first episode of EPN within ten days and then four days after reintroduction of SGLT2i. This case illustrates the potential for severe UTIs with SGLT2i and the value of a thorough history emphasizing the history of UTIs, especially those with obstructive renal symptoms.