Successful medical management of severe bilateral emphysematous pyelonephritis: case studies.

Abstract

Infections remain a major cause of morbidity and mortality in patients with diabetes in developing countries (1). Many infections are more common in patients with diabetes, and some occur almost exclusively in these patients. Emphysematous pyelonephritis (EPN) is an uncommon infection of the kidney characterized by production of gas within the renal parenchyma, collecting system, or perinephric tissue. Mostly confined to patients with diabetes (>90% of all cases occur in patients with diabetes), this life-threatening infection carries a mortality rate as high as 80% (2,3). The first case of EPN was reported by Kelly and MacCullum in 1898 (4). The term “emphysematous pyelonephritis” was recommended by Schultz and Klorfein (5) because of its emphasis on the relationship between the gas formation and the nature of the infectious process. Bilateral EPN (10%) is a rare phenomenon (6). The management of EPN has traditionally been aggressive, and nephrectomy is considered the treatment of choice (7). Such an approach in bilateral EPN would entail life long renal replacement therapy. Successful nonsurgical management of bilateral EPN has been previously reported (8). This article describes two additional cases in which bilateral EPN was successfully managed medically. M.K. was a 20-year-old woman who had had type 1 diabetes for 12 years, complicated by azotemic nephropathy, peripheral neuropathy, and nonproliferative diabetic retinopathy. She had been contracting recurrent urinary tract infections for the past 2 years and presented with a high-grade fever (temperature 102°F), bilateral flank pain, and repeated vomiting for 1 week. Oral ciprofloxacin prescribed by her general practitioner had provided no relief. Clinical examination revealed a distressed, apparently ill patient with tachycardia, tachypnea, pallor, dehydration, hypotension (blood pressure …