Diagnosis Of Emphysematous Pyelonephritis Research Articles

Emphysematous Pyelonephritis with Extension of Air in the Inferior Vena Cava

A 60-year-old gentleman with uncontrolled diabetes (HbA1C- 10.3%), presented with fever and chills, and right flank pain with dysuria for a week with no respiratory symptoms. On examination, he had tachycardia with a pulse rate of 130/min, blood pressure of 96/60 mm Hg, respiratory rate of 20/min, and saturation of 95% on room air. Per abdominal examination revealed left flank fullness (Fig.-1) and tenderness. On laboratory evaluation, he had a leucocyte count of 36700 cells/mm, a platelet count of 4.1 lakhs, and a blood glucose of 385 mg/dl. On the renal function test- serum creatinine was raised - 2.2 mg/dl. Urine analysis showed 25-30 leukocytes/HPF and the presence of sugar and no ketones. The report of urine culture obtained later was positive for Escherichia coli sensitive to Piperacillin + tazobactam. CXR was normal. Computed Tomography (CT) KUB (Fig.-2) revealed thinning of the right renal parenchyma along with large air pockets of perinephric emphysematous changes with the extension of the gas into IVC and left renal vein (Huang and Tseng classification 3b). Considering the above history, examination, and relevant investigation, a diagnosis of emphysematous pyelonephritis with a further extension of air in the inferior vena cava was made. The patient was treated with intravenous fluids, Piperacillin + tazobactam, metronidazole, and insulin. After stabilization, under general anaesthesia, the patient underwent open nephrectomy (Fig. 3) instead of PCN or DJ as the patient was hemodynamically stable, and bedside 2 D Echo did not reveal the extension of the gas into the atrium or ventricles, it was thought that removing the kidney as the source of gas production would curtail the process of intravasation of gas in the IVC. The patient underwent postoperative CT KUB after 72 hours which revealed complete spontaneous resolution of air in IVC (Fig.-4). The patient improved clinically with intensive post-operative care and was discharged after 14 days.

Clinical profile and outcome of emphysematous pyelonephritis presenting to a tertiary care hospital

BackgroundEmphysematous pyelonephritis is a necrotizing infection of the renal parenchyma by gas-forming organisms. The diagnosis of emphysematous pyelonephritis is made by clinical features and the detection of air in the renal parenchyma. In the past, nephrectomy was considered the only treatment option with a high mortality rate, but with advances in minimally invasive conservative techniques and better antibiotic treatment, the rate of kidney salvage has increased.Case presentationFrom January 2019 to December 2022, eight cases of emphysematous pyelonephritis were diagnosed based on clinical features and documentation of gas in the renal parenchyma by a Computed tomography scan. The mean age was 61.75 ± 4.3 years. 62.5% were female and 75% were diabetics. E. coli was the most common pathogen (87.5%). All 8 patients underwent early interventions in the form of DJ stenting or percutaneous nephrostomy tube insertion with only one patient requiring nephrectomy without any immediate mortality.ConclusionEmphysematous pyelonephritis is more common in women and the elderly. Diabetes mellitus and nephrolithiasis are major risk factors. E. coli was the most frequently isolated pathogen. Early diagnosis and early minimally invasive intervention in the form of a DJ stenting or percutaneous nephrostomy reduced the rate of nephrectomy and mortality.

Class 4 emphysematous pyelonephritis with emphysematous cystitis: a rare case report

Class 4 emphysematous pyelonephritis with emphysematous cystitis is an uncommon diagnosis. We report a case of class 4 emphysematous pyelonephritis with emphysematous cystitis, occurring in a young Bangladeshi diabetic lady, who presented with features of upper urinary tract infection and the diagnosis of emphysematous pyelonephritis was confirmed by computed tomography scan. She was treated conservatively. BIRDEM Med J 2023; 13(3): 160-162

A Lethal Case of a 3B Stage Emphysematous Pyelonephritis

Emphysematous pyelonephritis (EPN) is a rare, necrotising infection of the renal parenchyma, leading to the accumulation of gas within the kidney and in the perinephric space. Patients with diabetes account for 85-100% of cases. The current treatment is one of the potent antimicrobial therapies together with kidney drainage and fluid resuscitation. Nephrectomy should be considered if patients deteriorate or do not improve on conservative treatment. We report a case of 62-year-old woman with multiple comorbidities, with a diagnosis of EPN whose condition did not improve despite the standard treatment approach.

What is the prognosis of emphysematous pyelonephritis associated with extended-spectrum beta-lactamases producing microorganisms?

ObjectiveTo describe the microbiological characteristics in emphysematous pyelonephritis (EPN), demonstrate the frequency of extended-spectrum beta-lactamase (ESBL) microorganisms, and determine if these microorganisms are associated with the prognosis of patients with EPN. MethodsWe conducted a retrospective study in patients with a diagnosis of EPN in a tertiary care hospital of the northeast region of Mexico during the period from January 2011 to January 2016. Clinical variables were analyzed to determine association with the presence of ESBL-producing microorganisms. Statistical significance was set with p<0.05. ResultsA total of 63 patients were included; 55 (87.3%) of them were females, with a median age of 55 (interquartile range: 45–65) years. Conservative management was indicated in 38.1%; 42.9% were treated with ureteral stent; 12.7% with open or percutaneous drainage; 15.8% with early nephrectomy; and 9.5% with delayed nephrectomy. Reported mortality was 13 (20.6%) cases; 23 (36.5%) cases required admission to the intensive care unit. The most frequent microorganism isolated was Escherichia coli (n=34, 53.9%). ESBL microorganisms were found in 31.7% of the population. No significant association of ESBL was found with admission to the intensive care unit, or with increased mortality. ConclusionsTo our knowledge, this is the first study that evaluates ESBL microorganisms as a prognostic factor in EPN. Risk factors associated with a poor prognosis in patients with EPN have been described. The microbiological factors, specifically ESBL-producing bacteria, do not seem to influence in the prognosis of these patients.

Emphysematous pyelonephritis (EPN): A prospective study on management modalities and outcome in a tertiary care hospital

Background: EPN was a rapidly progressive, fulminant, life threatening, necrotizing infection of kidneys and perinephric space. EPN was most commonly seen in patients with diabetes mellitus.Aim and Objective: To study the clinical features, radiological classification, risk factors, Prognostic factors and management Modalities of Emphysematous pyelonephritis. Methodology: 54 patients who were diagnosed to have Emphysematous pyelonephritis from various departments in Nizam’s institute of medical sciences from December 2016 to November 2019 were included in the study. The diagnosis of EPN was confirmed by plain CT KUB scan. Results: Of the 54 patients 16 were male and 38 were female. 40 patients with EPN had diabetes mellitus (DM). There was 4 patients who was diagnosed to have DM after admission. Left kidney involved in 51.80% (28) of patients. Right kidney in 37.03% (20) of cases. Out of 54 patients, 14 patients who were presented to us with EPN had a pre-existing CKD. Only 14 out of 54 patients with EPN had normal renal parameters. Thrombocytopenia was seen in 32 of these patients and 4 of patients with thrombocytopenia required platelet transfusion. Urine culture was sterile in 3 patients. E.coli was grown in 42 patients and klebsiella in 3patients. There were 14 patients with dry EPN and 40 patients with wet EPN. 21.8% (12) patients has class 1 EPN. 43.75% (24) of patients had Class 2 EPN (Commonest class in our study), 25% (13) of patients had class 3A EPN, 3.1% (2) had class 3B EPN, 6.25% (3) has Class 4 EPN. The mean follow up was 8 months, ranging from 3 months to 24 months. 40 patients are under regular follow up. Conclusion: Pre-existing CKD status, shock at presentation and altered sensorium are the poor prognostic factors in this study.

Эмфизематозный пиелонефрит: эпидемиология, современные подходы к диагностике и лечению

Introduction. Emphysematous pyelonephritis (EPN) is a rare form of acute suppurative pyelonephritis, which is characterized by a rapid and severe course due to the pathogenic effect of the gas-forming bacterial flora. Currently, only a few hundred clinical cases of EPN are described in the literature. Currently, there are no standards for the surgical treatment of patients with EPN, but there is a clear tendency towards a wider use of minimally invasive methods of treatment and limitation of indications for nephrectomy. A risk-based approach based on the proposed radiological classifications of EPN is considered preferable. Purpose. Тo study all literature sources available for the current period on the Internet, describing clinical cases and experience in treating patients with a diagnosis of emphysematous pyelonephritis. Materials and methods. Тhe results of a search in the scientific databases PubMed, MEDLINE, Embase, elibrary were analyzed for the queries «emphysematous pyelonephritis», «classification», «gassing bacterial flora», «diabetes mellitus», «conservative treatment», «nephrectomy», «percutaneous drainage». 754 scientific publications were found, 25 were selected for detailed analysis. Results and discussion. Today, there are no standards for surgical treatment of patients with EP, but there is a clear trend towards wider use of minimally invasive methods of treatment and limiting the indications for nephrectomy. Minimally invasive methods of treating EN allows organ-preserving treatment and reduces the risk of renal failure. The lack of clear indications for the choice of the scope of surgical treatment and the low orientation of specialists towards radiological diagnostic criteria are the main reasons for excessive organ-carrying treatment of patients with PF. A risk-mediated approach based on the proposed clinical and radiological classifications of EP is considered preferable. In controversial cases, it is possible to recommend an attempt at minimally invasive treatment in combination with adequate conservative therapy, and only if it is ineffective, resort to performing nephrectomy. Conclusion. Indications for nephrectomy should be strictly limited and revised taking into account modern approaches. Nephrectomy should be an option of choice only if conservative treatment is impossible or ineffective.

Emphysematous Pyelonephritis in a Horseshoe kidney

Emphysematous pyelonephritis is a necrotizing renal infection that results in the presence of gas in renal parenchyma, collecting system, and surrounding tissues. Ninety-five percent of the patients have underlying uncontrolled diabetes mellitus, but non-diabetic patients may be affected due to ureteral obstruction and infection with gas forming pathogens. Several poor prognostic factors have been described, such as thrombocytopenia, acute kidney failure, impaired consciousness, and shock. We present a case of a 41-year-old female who attends to the emergency department with signs of septic shock and diffuse abdominal pain. The diagnosis of emphysematous pyelonephritis in a horseshoe kidney was confirmed.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification. A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS®. Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality. Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Pathology of emphysematous pyelonephritis: A study of 11 cases

Objective: The objective was to study the pathological features of emphysematous pyelonephritis (EPN). Materials and Methods: A total of 11 nephrectomy specimens of EPN received in the surgical pathology section of a tertiary hospital in a metropolis city during the period 2005-2014 are included in this study. Clinical details were obtained from the patients' records. All the patients had undergone total nephrectomy. All the specimens were fixed in 10% buffered formalin and processed for paraffin wax sectioning. The sections were stained with hematoxylin and eosin stain. Results: The most common symptoms were fever and costovertebral pain. Diabetes mellitus was present in 9 out of 11 cases and one case had calculus in the pelvis. One patient had underlying diabetes which was undiagnosed during the nephrectomy. Diagnosis of EPN was confirmed by the presence of gas and fluid in the renal tissue by computed tomography. The left kidney (nine cases, 81%) was more frequently affected than the right kidney (two cases, 19%). EPN occurred in 40-60 years of age (mean age 51.5%), and out of 11 patients, 8 (81%) were female. Escherichia coli was the commonly isolated organism from urine. Eight cases were of Type II EPN and three cases were Type I EPN. Histopathologic examination of all the cases of EPN showed acute suppurative (necrotizing) inflammation of renal parenchyma and perirenal tissues associated with vasculitis of vessels and infarction. Conclusion: EPN is most commonly seen in patients with diabetes mellitus, and E. coli is the most common causative organism.

Emphysematous Pyelonephritis, Case Report and Review of the Literature

Background: Urinary tract infections in immunosuppressed patients, especially Diabetic ones with poor control, can progress to a severe necrotizing infection called emphysematous pyelonephritis (EP), a diagnosis that must be highly suspected in these cases for the presentation as a simple urinary tract infection with poor response to medical management. Delayed diagnosis increases the already high morbidity and mortality. Case: We present the case of a 47-year-old female admitted to emergency department for a 4 day disease characterized by fever, chills, adynamia, asthenia and right flank pain of moderate intensity. Past day she refers hematemesis in an occasion. She denied pathologic background. At physical examination with inflammatory response signs, right flank pain, positive Giordano sign and positive superior ureteral points, without signs of peritoneal irritation. Laboratories report white blood cells 13000/mm3, Hemoglobin 13.7 g/dL, Platelets 82000, Glucose 595 mg/dL, Cr 2 mg/dL. Gas Analysis report metabolic acidosis. Urianalysis report leucocytes >75μL, uncountable red blood cells, bacteries +++, nitrites+++ Glucose +++, proteins +, ketones ++. Pyelonephritis and Diabetes mellitus 2 of recent diagnosis was established. After two days of medical treatment she presented septic shock with acute renal failure AKIN II, hematological and hepatic disfunction. Mechanic ventilatory support and use of norepinephrine were adhere to therapy. This case was present in a rural hospital and the unique auxiliary imaging available was an abdomen X-ray that shows an air bubble in the right perirenal space. The diagnosis of emphysematous pyelonephritis was settled down and urgent right nephrectomy performed after platelet transfusion. The surgery was successful and without complications finding a right kidney of 9x6x4 centimeters with multiple parenchymal abscesses. After 11 days patient was discharged uneventfully. Conclusion: The diagnosis of EP must be highly suspected in Diabetes mellitus 2 patients with severe urinary tract infection and poor response to initial medical management. Medical management including parenteral antibiotics plus percutaneous catheter drainage or nephrectomy must be performed immediately according to the risk factors by the high morbidity and mortality associated with this disease.

Emphysematous Pyelonephritis with Abscesses Masquerading as an Ordinary Urinary Tract Infection

Emphysematous Pyelonephritis (EPN) is a rare, gas-forming infection of the renal parenchyma associated with significant morbidity and mortality. We report the case of a 39 year-old woman with uncontrolled diabetes who presented with abdominal pain, fevers and chills for one month. Physical exam was notable for dry oral mucosa and left costovertebral angle tenderness. Labs showed acute kidney injury and a hyperglycemic hyperosmotic state. CT abdomen revealed emphysematous pyelonephritis with a large left renal abscess. EPN should be considered in diabetic patients, especially those with uncontrolled or new-onset diabetes and those presenting with symptoms of urinary tract obstruction. Prognostic factors include thrombocytopenia, shock, altered mental status and need for hemodialysis. Our patient was treated successfully with intravenous antibiotics, percutaneous drainage, strict glucose control and monitored with serial imaging. She underwent laparoscopic nephrectomy one month later. Early diagnosis of EPN is essential as it carries a high mortality and a strong clinical suspicion is required, as patients may have an atypical presentation.

Clinico-radiological Features and Classification of Emphysematous Pyelonephritis: A prospective study

Emphysematous pyelonephritis (EPN) is a rare, severe acute, necrotizing infection of the kidney characterized by presence of gas within the renal parenchyma, collecting system and perirenal tissues. It is commonly caused by ascending infection due to E.coli. Other gas forming organisms like Klebseilla, proteus etc. may spread by hematogenous route. A patient especially if a woman, with poorly managed diabetes, presents with urinary tract infection, sepsis and renal insufficiency. Ultrasound and CT plays an invaluable role in the diagnosis and management. In our study, nine patients of EPN were studied during the period of 2011-2013. All the patients were diabetics, invariably presented with fever, abdominal discomfort or pain at the time of presentation. Pus in urine with raised TLC with leukocytosis was seen in all of them. Urine culture showed bacterial growth in 5(55.5%) patients, with E. coli, the commonest organism. All patients had hyperglycemia with mean blood sugar level was 354mg/dl. Serum creatinine was raised with mean level of 3.7mg/dl suggesting renal dysfunction. The male to female ratio was 1:3.5 with age range of 42-65 years. Radiological investigations like plain X ray, Ultrasound and Computed tomography of abdomen showed pockets of air in the renal regions in all 9(100%)patients, bilateral in two(22.3%) and unilateral in 7(77.7%) patients. Mild hydronephrosis was seen in 1(11%) patient. Perinephric extension of gas with perinephric collection was noted in 4(44.5%) patients. After clinicoradiological investigations the diagnosis of EPN was made with 2(22.3%) cases of Type I EPN and 7(77.7%) cases of Type II EPN.DOI: http://dx.doi.org/10.3126/njr.v4i1.11368 Nepalese Journal of Radiology, Vol.4(1) 2014: 38-46

Emphysematous pyelonephritis: case report and literature review

To explore the diagnosis and treatment of emphysematous pyelonephritis so as to improve its diagnosis and reduce its mortality. The clinical data were retrospectively analyzed for 2 diabetic patients with emphysematous pyelonephritis. Their symptoms included high fever, chills and lumbago. Computed tomography (CT) scans were performed to reach a definite diagnosis of emphysematous pyelonephritis with gas within renal parenchyma and/or perirenal tissue. Both received intravenous antibiotics. One patient underwent open abscess drainage while another percutaneous puncture under ultrasonic guidance. Their conditions improved and healed. CT scan is an efficient imaging modality for early diagnosis. The combination of antibiotics and early drainage may offer a better outcome. Key words: Emphysema; Pyelonephritis

Emphysematous Pyelonephritis in a Patient With Hyperosmolar Hyperglycemic Syndrome

A 61-year-old woman presented with abdominal and back pain, and disturbed consciousness. Laboratory data showed hyperglycemia (plasma glucose 448 mg/dl), leukocytosis, thrombocytopenia, renal failure, and extremely increased serum C-reactive protein level. Urinalysis revealed no ketone bodies, and numerous bacteria and leukocytes. These symptoms and data suggested the presence of diabetic hyperosmolar hyperglycemic syndrome and urinary tract infection. Computed tomography (CT) of the abdomen showed the presence of gas in the renal area with extensive renal parenchymal destruction, indicating the diagnosis of emphysematous pyelonephritis, which is a rare but severe disease with a morality rate that can be as high as 70%. Early diagnosis by abdominal CT and early intensive therapy using intensive insulin therapy, antibiotics, and selective nephrectomy saved her life. doi:10.4021/jmc121w

Emphysematous Pyelonephritis in a Patient With Hyperosmolar Hyperglycemic Syndrome

A 61-year-old woman presented with abdominal and back pain, and disturbed consciousness. Laboratory data showed hyperglycemia (plasma glucose 448 mg/dl), leukocytosis, thrombocytopenia, renal failure, and extremely increased serum C-reactive protein level. Urinalysis revealed no ketone bodies, and numerous bacteria and leukocytes. These symptoms and data suggested the presence of diabetic hyperosmolar hyperglycemic syndrome and urinary tract infection. Computed tomography (CT) of the abdomen showed the presence of gas in the renal area with extensive renal parenchymal destruction, indicating the diagnosis of emphysematous pyelonephritis, which is a rare but severe disease with a morality rate that can be as high as 70%. Early diagnosis by abdominal CT and early intensive therapy using intensive insulin therapy, antibiotics, and selective nephrectomy saved her life. J Med Cases. 2011;2(1):37-38 doi: https://doi.org/10.4021/jmc121w

Emphysematous Pyelonephritis: Tertiary Care Center Experience in Management and Review of the Literature

Introduction: In recent years there have been changes in management modality and a lower mortality with conservative management. We analyzed the result of emphysematous pyelonephritis (EPN) management by a review of the literature. Material and Methods: We made a retrospective study for the period from August 2005 to July 2009. Patients were evaluated by CT and subclassified based on CT. The patients managed in different modalities and their outcomes were compared. Results: A total of 28 patients were admitted with the diagnosis of EPN. The age range was 22–70 years. Five patients were managed conservatively, 17 patients underwent minimally invasive modalities (double J stent, pigtail drainage). Open drainage of the abscess was conducted in 2 patients, and 4 patients required emergency nephrectomy. Emergency nephrectomy is associated with a high mortality (75%). Conclusions: In the majority of cases, EPN was successfully treated by resuscitation and minimally invasive modalities. Percutaneous drainage should be part of the initial management strategy. This strategy is associated with a lower mortality than emergency nephrectomy.

Imaging of Emphysematous Pyelonephritis: Self-Assessment Module

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the role of imaging in the diagnosis of emphysematous pyelonephritis and the impact of CT findings on the management of emphysematous pyelonephritis.

Emphysematous Pyelonephritis—A Case Report

A 46 year old woman with complaints of high grade fever with chills and rigor and abdominal pains for 1 week presented with shock and acute renal failure and her blood sugar was found to be highly elevated. CT scan showed extensive destruction of right renal parenchyma with gas collection within the parenchyma and in the perinephric region thus confirming the diagnosis of emphysematous pyelonephritis. The clinical presentation and radiological findings of EPN are discussed.

Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis

We aimed to study the clinical profile, prognostic factors, and the 6-month outcome of patients with emphysematous pyelonephritis (EPN) METHODS: All patients admitted with a diagnosis of emphysematous pyelonephritis between January 2001 and July 2007 were included. Overall 19 cases were diagnosed to have emphysematous pyelonephritis. There were 16 females and three males. Fourteen cases had type 2 diabetes mellitus. Fourteen cases had unilateral involvement and five had bilateral involvement. Eleven cases were classified as having class 1 or 2 disease and eight cases had class 3 and 4 disease. E. coli was the most common organism cultured (68.4%). Five cases underwent percutaneous drainage of the collecting system and three cases had nephrectomy of which 10.5% (two with advanced disease) expired. Shock at admission (p = 0.03), serum creatinine >5.0 mg/dl (p = 0.035) and DIC (p = 0.017) were independent poor prognostic factors. There was no difference in the prognosis between patients who had >or=2 or <2 poor prognostic factors (p = 0.16). However, prognosis was not related to disease class, unilateral vs. bilateral involvement, sepsis or the age of the patient. At 6 months, two patients were on maintenance hemodialysis. In cases of EPN, shock, serum creatinine >5.0 mg/dl and DIC at admission are poor prognostic factors. Larger prospective studies are needed to confirm our findings.