Emphysematous Pyelitis Research Articles

Gas-Containing Kidney Stones: A Case Report

Gas-containing kidney stones are rare cases. The available literature about gas in the kidneys, usually only discusses and distinguishes between two things, namely emphysematous pyelonephritis and emphysematous pyelitis, after getting rid of recent upper urinary tract instrumentation and the presence of fistula with the gastrointestinal tract. To date, there have been only 11 cases of gas-containing kidney stones. We report the 12th case of gas-containing kidney stones (the first from the field of radiology), which is a 69-year-old female with bilateral flank pain, no fever, and no history of other diseases. Physical examination revealed bilateral costovertebral angle tenderness. The plain abdominal radiograph showed a staghorn stone in the right kidney. The non-enhanced CT abdomen showed gas-containing staghorn stones in the right kidney accompanied by hydronephrosis. The patient underwent percutaneous nephrolithotomy. Kidney stone analysis showed oxalate, phosphate, ammonium, calcium, and uric acid components. The etiology and relationship of gas-containing kidney stones with other gas entities in the kidney is still unclear, making it difficult to determine their clinical significance. Radiological examination, especially CT scan, plays a very important role in determining the entity of gas in the kidney.

Kidney Stones Vanished into Thin Air: Distinguishing Emphysematous Pyelitis from Renal Calculi on Ultrasound

Emphysematous pyelitis (gas within the excretory system) is a rare infection with a mortality of 20%. Although, it may resolve with antibiotics alone, the presence of gas within the kidney must be detected and clearly distinguished from uncomplicated pyelonephritis or calculi. Acoustic shadowing on ultrasound (i.e. the drop in echo strength under a highly reflective or attenuating structure) can be useful in this situation. This can distinguish calcification (clean shadowing) or bone (partial shadowing) and gas (dirty shadowing). To highlight the importance of the correct interpretation of this imaging artifact we describe the course of a 64 years old woman who presented with fever, left flank pain and dysuria. The renal tract ultrasound was initially reported to show multiple renal calculi. However, on re-review it was noted that the appearance of the acoustic shadowing was more consistent with air. The diagnosis of emphysematous pyelitis was confirmed by computed tomography.

MO091BILATERAL EMPHYSEMATOUS PYELITIS: A CASE REPORT AND ULTRASONOGRAPHY FEATURES

Abstract Background and Aims Emphysematous pyelitis is a rare urinary infection with gas formation in the excretory system. Diabetes mellitus and urinary tract obstruction are the main risk factors. Most patients are women over 60 years old. The pathogenesis is unknown. Diabetes mellitus and the elevated glucose levels may create a favorable microenvironment for gas-forming microbes, but it does not exhaustively explain clinical and pathological symptoms. Escherichia Coli and Klebsiella Pneumoniae are the most involved bacteria. Clinical features are the same as other forms of pyelonephritis e.g. fever, chills, flank abdominal pain, nausea and vomiting. Ultrasonography, and especially computed tomography (CT) are important diagnostic tools for demonstration of gas within pelvicalyceal system, urethers or even in bladder. Use of parenteral antibiotic, relief of urinary tract obstruction if present, percutaneous catheter drainage of gas and purulent material and nephrectomy are the mainstays of therapy. This report introduces a case of bilateral emphysematous pyelitis with emphasis on its ultrasound presentation. This is one of the few cases of bilateral emphysematous pyelitis reported in literature. Method A 49-year-old female presented to the emergency with asthenia, epistaxis, orthostatic hypotension and nocturnal cramps. Two months before she was referred to Department of Nephrology for proteinuria. In that occasion, renal ultrasound showed normal kidneys and renal biopsy was performed. She started oral therapy with corticosteroid for ANCA-negative vasculitis and iatrogenic diabetes mellitus occurred. She was admitted again to our Department of Nephrology, blood test was performed and revealed: white cell count 20.500/ml; glucose 243 mg/dl; serum creatinine 2.3 mg/dl; C-reactive protein, 0.65 mg/dl ( < 0.5), procalcitonin 2.05 µg/l (nv < 0.5). Urine culture was positive for E. Coli. Results Renal ultrasound revealed the presence, in both kidney pelvises, of multiple and diffuse hyperechogenic images associated with some reverberation artefacts. The ultrasound findings were unusual and of doubtful interpretation: staghorn calculi, encrusted pyelitis, gas? (Fig. 1, 2). Reverberation artifacts give rise the suspicion of gas presence in kidney pelvises, usually absent in case of staghorn calculi and encrusted pyelitis. CT confirmed the diagnosis of bilateral emphysematous pyelitis due to the diffuse presence of gas within the renal calyces, also extending to the ureters and bladder lumen (Fig. 3). We promptly started parental antimicrobial therapy with cefalosporine. After one week we observed a clinical and laboratory improvement, and the renal ultrasound revealed the resolution of bilateral pelvises alteration (Fig. 4). Conclusion In emphysematous pyelitis, renal ultrasound is characteristic due to the presence of diffuse hyperechogenic images located in the renal pelvis associated with some reverberation artifacts, usually absent in case of renal stones. Therefore, the renal ultrasound in association with clinical and laboratory findings, especially in patient with positive urine culture, should arouse the suspicion of emphysematous pyelitis to start promptly antimicrobial therapy, even when CT examination is not immediately available.

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound.

IntroductionPoint-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN).Case ReportA 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with “dirty shadowing” within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation.ConclusionDistinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.

Bilateral Xanthogranulomatous Pyelonephritis due to Staphylococcus Schleiferi: An Uncommon Presentation

Xanthogranulomatous pyelonephritis (XGP) describes a rare infectious disease with a destructive granulomatous process. The literature contains few cases of bilateral XGP and no cases due to Staphylococcus schleiferi; we diagnosed it with the advance at imaging and bacterial identification systems technology. This is a case of a 22-year-old female at our emergency department complaining of abdominal pain, nausea, emesis, dyspnea of 3 weeks. Medical history included Chronic Kidney Disease (CKD) treated with Peritoneal dialysis and history of recurrent urinary tract infection. On examination, we found signs of septic shock and suprapubic tenderness. No flank or renal mass found on examination. Tomography (CT) scan showed bilateral kidney enlargement with pyelocaliceal dilatation due to stones obstructing ureteral union; presence of gas on left kidney´s renal pelvis and an abscess in the posterior pararenal space. We diagnosed Bilateral XGP and emphysematous pyelitis, initiated board-spectrum antibiotic and perform urgent right nephrostomy and left nephrectomy. The urinary, blood and renal tissue culture identified pathogenic agents (Escherichia coli and Staphylococcus schleiferi) and antibiotic treatment was de-escalated. After two weeks of treatment, she recovered of an acute on chronic renal failure (ACRF) remaining with 24ml/min/1.73m2 of GFR (stage IV of CKD) and was discharged from hospital.

Acute Renal Infection in Adult, Part 2: Emphysematous Urinary Tract Infection—What the Radiologist Needs to Know

AbstractRenal emphysema, as described by Kelly and MacCallum in 1898, refers to the spontaneous generation of gas within the renal parenchyma and surrounding tissues. Since its initial description, it has become apparent that the spectrum of radiologically visible renal and perirenal gas includes three distinct clinical entities: (1) emphysematous pyelonephritis, a necrotizing infection associated with gas formation in the renal parenchyma, (2) emphysematous pyelitis, in which gas is confined to the renal pelvis and calyces, and (3) gas-forming perinephric abscess. In this article, we will review gas-forming infections of the urinary system in terms of radiological features, clinical manifestations, predisposing factors, and appropriate management guidelines.

Is emphysematous pyelitis a precursor lesion of emphysematous pyelonephritis? A case report of bilateral emphysematous pyelitis caused by extended-spectrum beta-lactamase Escherichia coli and literature review

The presence of air in different parts of renal excretory system needs accurate assessment, and careful consideration as its progression to renal parenchyma can lead to fulminant course with substantial mortality. Bilateral emphysematous pyelonephritis is a well-known entity, but bilateral emphysematous pyelitis (EP) along with emphysematous cystitis is extremely rare. An internet search with the term “bilateral emphysematous pyelitis” and “bilateral emphysematous pyelitis and ureteritis with cystitis” only found three case reports in English. We present an interesting case of bilateral EP, ureteritis, and cystitis in a nondiabetic male patient without any history of immunodeficiency (HIV or chronic steroid use) but with a history of nonobstructing bilateral multiple renal calculi who was successfully managed medically. EP, if diagnosed early and managed properly, has an excellent prognosis with complete recovery following medical treatment. The following core competencies are addressed in this article: Practice-Based Learning and Improvement, Patient care and Procedural skills, Medical Knowledge.

Emphysematous Pyelitis With Query Intraparenchymal Involvement

We report the ccase of a 65-year-old woman presenting with urosepsis in the context of a one-week history of progressive right flank pain and a past medical history of type 2 diabetes mellitus. Computed Tomography (CT) demonstrated evidence of emphysematous pyelitis, a rare infection caused by gas-producing bacteria associated with elevated blood glucose. The patient responded well to fluid resuscitation and was discharged home with follow-up arranged for blood sugar management and outpatient lithotripsy addressing obstructive renal calculus.

Résultats du traitement conservateur de la pyélonéphrite emphysémateuse

IntroductionEmphysematous pyelonephritis (EPN) is a rare and severe, necrotizing infection of the kidney. Diagnosis should be precocious based on computed tomography (CT). Its management remains controversial and its treatment is currently increasingly conservative. The aim of this paper is to discuss the conservative treatment of this disease through our experience in 21 patients. Material and methodsA retrospective analysis including 21 patients managed conservatively for an emphysematous pyelonephritis in our department from January 2010 to April 2015. Follow-up ranged from three to 24 months. ResultsOf the 24 patients, seven belonged to class 1, twelve to class 2 and two to class 4. Obstruction of the upper urinary tract was found in 16 cases. On the risk factor stratification, thrombocytopenia was found in five cases, renal function impairment in 10 cases and a septic shock in four cases. All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad-spectrum antibiotics. Drainage of the urinary tract was performed by double-J stent in 14 patients and with ureteral catheter in six patients. One patient had urinary distension secondary to a urethral stricture with bilateral emphysematous pyelitis. In this case, drainage consisted in suprapubic bladder catheter only. The outcome was favorable in 18 patients and the control CT showed a decline or complete disappearance of gas in urinary tract and/or renal parenchyma after an average period of 12 days. A secondary nephrectomy was performed in two cases. Specific mortality rate was zero. ConclusionPNE remains a severe infection involving the vital prognosis. Computed tomography makes an early diagnosis. Treatment should be conservative based on the association of medical intensive care and drainage, percutaneous or endoscopic, urgently. Nephrectomy should be reserved for extensive forms with multiple organ dysfunction or failure of conservative treatment.

Emphysematous Pyelitis Disguised as Cholestasis and Jaundice

Emphysematous pyelitis is a rare infection of the renal pelvis occurring alone or in association with pyelonephritis. The most common cause is E. coli and diabetes is the strongest risk factor. In a retrospective review including 48 patients who were diagnosed with either emphysematous pyelitis or pyelonephritis, the mean patient age was 60 years old and women outnumbered men 6:12. The most common initial symptoms include fever, dysuria, abdominal pain, and flank pain. The most frequent organ system involvement is hematologic and renal. Our patient, a 76 year old female, with no past medical history, presented with progressive weakness followed by the onset of jaundice. Her exam was notable for hypertension but no fever, jaundice, epigastric/right upper quadrant abdominal tenderness or peritoneal signs. Labs were remarkable for a profound leukocytosis, anemia, cholestasis, and an elevated creatinine. An abdominal ultrasound did not reveal cholecystitis or a common bile duct obstruction. Empiric antibiotics to include Ceftriaxone and Flagyl were started for possible cholangitis. On hospital day two, an abdominal endoscopic ultrasound was performed in lieu of a contrast study as renal function had worsened. This examination was normal. A non-contrasted CT scan of the abdomen and pelvis demonstrated the unusual findings of emphysematous pyelitis with a surrounding fluid collection concerning for a perinephric abscess. Subsequent management included placement of a percutaneous nephrostomy tube and antibiotics. Emphysematous pyelitis presenting as cholestasis is a novel clinical presentation of a rare illness.

“I have chicken fat in my urine!” A case of Candida tropicalis induced emphysematous pyelitis

A patient with uncontrolled diabetes mellitus presented with fever and flank pain. A computed tomography scan showed free air within both collecting systems. A diagnosis of emphysematous pyelitis was made after other alternative diagnoses were ruled out. Urine culture grew Candida tropicalis. The emphysematous pyelitis resolved with conservative management using antifungal therapy.

Pielite enfisematosa unilateral: relato de caso

Relata-se um caso de paciente de 22 anos de idade, gênero feminino, que foi admitida no pronto-socorro com lombalgia aguda, disúria, vômitos e febre (38,5ºC). Os achados de exames de urina e tomografia computadorizada demonstraram infecção no trato urinário associada a gás no sistema coletor, configurando pielite enfisematosa unilateral por Gram-negativo. O presente relato enfatiza a ocorrência deste agravo como complicação de infecção no trato urinário.

Emphysematous cystitis and emphysematous pyelitis: a clinically misleading association

We present a rare case of emphysematous cystitis associated with an emphysematous pyelonephritis in a diabetic Arab man who was admitted in a confusional state. A 60-year-old man was admitted to the emergency department with confusion and hypogastric mass. The Clinical examination found comatose patient with a mass in the tympanic hypogastric percussion. The pelvic computed tomography (CT) demonstrated intramural gas in the urinarytract, which suggested a diagnosis of emphysematous cystitis and emphysematous pyelitis. The treatment was based on an antibiotics associated with a bladder drainage and diabetes stabilization. The evolution was uneventful. Every diabetic patient with a urinary tract infection who seems to be severely ill should have an abdominal X-ray as a minimal screening tool to detect emphysematous complications. The rarity and the association with an emphysematous pyelitis, which is rarely reported in the literature, are two remarkable characteristics described in this case report.

Emphysematous pyelitis, ureteritis and cystitis

A 36-year-old man with a history of gout and a congenital solitary right kidney with chronic hydronephrosis and non-obstructive megaureter of unknown etiology presented initially with a stone on KUB and flank pain. A computed tomography (CT) scan showed a right-sided calculus which was treated with extracorporeal shock wave lithotripsy and alkalinization therapy. Several weeks post-treatment, he presented to the emergency department with cloudy urine and dysuria. His urinalysis demonstrated pyruia and hematuria. He was empirically started on ciprofloxacin, but returned to the emergency department several days later with fevers, chills and rigors but no flank pain. His creatinine had risen from 109 mmol/L at baseline to 266 mmol/L, and his white blood cell count was 15.6 × 106/L. A CT scan failed to show any residual calculi; however, it demonstrated emphysematous pyelitis (Fig. 1, arrow) with concomitant emphysematous ureteritis and cystitis (Fig. 2, arrows). His urine culture revealed a multi-drug resistant E Coli and a percutaneous nephrostomy tube was arranged after a ureteric stent insertion was unsuccessful. His pre-nephrostogram scout x-ray showed a collecting system full of gas (Fig. 3, arrows demonstrating gas in ureter and renal pelvis). He was treated with nephrostomy tube drainage and intravenous ceftriaxone. Within 5 days, he had complete clinical and radiographical resolution of the gas in his collecting system, and his renal function returned to baseline. Subsequent pressure-flow studies of urinary drainage via the nephrostomy tube (Whittaker test) showed no evidence of ureteric obstruction. It is important to distinguish emphysematous pyelitis (gas in the collecting system) from emphysematous pyelonephritis (gas in the renal parenchyma), as the latter can be more severe. Fig. 1 The computed tomography scan with the arrow pointing to the emphysematous pyelitis. Fig. 2 The computed tomography scan with the arrows pointing to the emphysematous ureteritis and cystitis. Fig. 3 The patient’s pre-nephrostogram with the arrows demonstrating gas in the ureter and renal pelvis. Empysematous pyelitis is due to E. coli infection in 69% of cases and typically responds promptly to medical therapy.1

Emphysematous Pyelitis Complicated by Renal Calculi: A Case Report

Emphysematous Pyelitis Complicated by Renal Calculi: A Case Report

Poster 341: Development of Emphysematous Pyelitis from Self-Intermittent Catheterizations: A Case Report

Poster 341: Development of Emphysematous Pyelitis from Self-Intermittent Catheterizations: A Case Report

Air in the kidney: between emphysematous pyelitis and pyelonephritis

Presence of air in the kidney can be problematic as the location of the air in different parts of the kidney greatly affects the subsequent management and outcome of the patient. We present here a case of a patient who had emphysematous pyelitis, in which CT scan was able to display presence of air only in the collecting system, thus differentiating this condition from the more fulminant emphysematous pyelonephritis. This leads to a more favourable prognosis and outcome to the patient.

Renal emphysema in diabetic patients: CT evaluation

Renal emphysema is a rare, fulminant, suppurative infection of pelvicaliceal system, renal parenchyma, perinephric tissues, and retroperitoneum. It is characterized by formation of gas. Invariably this condition is associated with diabetes mellitus and carries high mortality (40-90%). Renal emphysema can be classified into two distinct clinical entities: emphysematous pyelitis and emphysematous pyelonephritis. This classification has important prognostic and therapeutic implications. Herein we describe the computed tomographic findings in five unilateral cases of renal emphysema (two cases of emphysematous pyelitis and three cases of emphysematous pyelonephritis) in five insulin-dependent diabetic patients.

Emphysematous Urinary Tract Infections: Diagnosis, Treatment and Survival (Case Review Series)

Emphysematous urinary tract infections are rare conditions, usually occurring in diabetic patients. Mortality rates in medically managed patients are reported to be as high as 70% to 90%. Growth of the diabetic population warrants heightened attention to these potentially fatal infections. We report a series of 5 cases with favorable outcomes. All patients were diabetic. Presenting symptoms included fever, chills, nausea, vomiting, and abdominal pain. On physical examination, two patients had costovertebral angle tenderness; a third was dehydrated; a fourth had dehydration and an abdominal mass; and a fifth patient had suprapubic tenderness. All cases had leukocytosis and impaired renal function. Computed tomography (CT) scan disclosed emphysematous pyelonephritis in 3 cases (gas within renal parenchyma and/or perirenal tissue), emphysematous pyelitis in 1 case (gas in collecting system), and emphysematous cystitis in 1 patient (gas within bladder wall). Urine culture of 1 case grew Enterococci, whereas in the other cases cultures yielded gas-producing organisms. All patients received intravenous antibiotics. Two patients underwent CT-guided abscess drainage; 2 cases had J-stent placement, and one patient was readmitted with septic shock and underwent nephrectomy. All the patients' conditions improved and they were discharged. Emphysematous urinary tract infections are usually caused by gas-producing organisms. They should be suspected in diabetic patients with urinary tract infections and worsening of renal function. CT scan is the method of choice for diagnosis and follow up. None of our patients died, mainly due to early diagnosis, sequential radiologic assessment, and timely surgical intervention when needed.

Bilateral emphysematous pyelonephritis

Emphysematous or gas forming infections, a very small percentage of bacterial infections of the urinary tract attract importance because of their life threatening potential. The spectrum of gas producing infections include emphysematous pyelonephritis, emphysematous pyelitis and emphysematous cystitis. The first case of ‘pneumaturia’ was reported in 1898 [1] and since then more than 200 cases of emphysematous pyelonephritis have been reported. Bilateral emphysematous pyelonephritis is much rarer infection with fewer than 10% emphysematous pyelonephritis. More than 90% of emphysematous pyelonephritis occurs in patients with poorly controlled diabetes [2]. This report represents this rare infection.