Emphysematous pyelonephritis: a rare but potentially life-threatening complication of poorly controlled diabetes

Abstract

A 50-year-old man with poorly controlled type 1 diabetes presented with a 48-h history of diarrhoea, vomiting and poor appetite. He had recently visited India where he was treated for enteric fever. On admission he was febrile, dehydrated, hypotensive and tachycardic with diffuse abdominal tenderness. Plasma glucose was 56.1 mmol/L, venous pH 7.11, and urinalysis showed significant ketonuria, confirming diabetic ketoacidosis. He was treated with intravenous fixed dose insulin and fluids. In view of his symptoms, an erect chest and abdominal X-ray were performed to exclude small bowel obstruction and perforation respectively. The abdominal X-ray showed a gas density adopting the outline of the right kidney. Computed tomography of the abdomen showed gas within the parenchyma of the right kidney, in keeping with emphysematous pyelonephritis, and also a right sided hydronephrosis and hydroureter. Blood cultures were positive for Enterobacter aerogenes. He was reviewed by the urologists and infectious diseases team, was started on intravenous meropenem and had a percutaneous nephrostomy, drainage of gas from the emphysematous region of the right kidney and ureteric stent insertion. He responded well to treatment and was discharged on a basal bolus insulin regime, with his nephrostomy and drain being removed before discharge. He is under out-patient review by the diabetes, urology and infectious diseases teams. Emphysematous pyelonephritis is a potentially life-threatening complication of poorly controlled diabetes, characterised by bacterial production of gas within the kidney parenchyma. Early diagnosis and multidisciplinary care can lead to good outcomes, avoiding the need for emergency nephrectomy.