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Emphysematous pyelonephritis in an alcoholic and diabetic patient

Published:September 24, 2022DOI:https://doi.org/10.1016/j.amjms.2022.09.019

      Case presentation

      A 56-year-old vagrant male patient with longstanding medically uncontrolled diabetes mellitus and alcoholism presented with fever and progressive lethargy for 2 days. On admission, fever with shock status were recorded. Blood test results were as follows: white-cell count, 14,860/mm3; C-reactive protein level, 18.96 mg/dL; procalcitonin level, >200 mmol/L; creatinine level, 3.2 mg/dL; and glycated hemoglobin level, 17.6%. Initially, chest X-ray revealed left upper abdominal bizarre gas pattern (Fig. 1A). Thus, computed tomography was arranged, which revealed emphysematous pyelonephritis (Fig. 1B). Blood culture yielded Klebsiella ozaenae. The patient received broad-spectrum antibiotic treatment and underwent retroperitoneal exploration operation with drainage of abscess. Continuous renal replacement therapy was performed because of septic shock, oliguria, and metabolic acidosis. Finally, the infection was controlled, and the patient's hemodynamic status was stabilized.
      Emphysematous pyelonephritis (EPN) is an acute, life-threatening, severe gas-forming infection of the renal parenchyma and surrounding perirenal tissues, requiring emergency care and surgical intervention. EPN can be easily misdiagnosed because of abnormal gas pattern on plain radiography, including a streaky or mottled, bubbly, rim-like, crescent-shaped gas pattern.
      • Wan Y.L.
      • Lee T.Y.
      • Bullard M.J.
      • et al.
      Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome.
      Therefore, imaging techniques, such as computed tomography, are performed to diagnose EPN more accurately. The main risk factor of EPN is diabetes mellitus, which can provide gas-forming microbes with a microenvironment favorable for their growth.
      • Huang J.J.
      • Tseng C.C.
      Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis.
      However, the best therapeutic modalities for EPN remain controversial. Previous studies have found that percutaneous drainage and medical management were associated with higher survival rates than nephrectomy. Therefore, nephrectomy should only be considered in cases wherein the condition of the patient does not improve despite other treatments.
      • Aboumarzouk O.M.
      • Hughes O.
      • Narahari K.
      • et al.
      Emphysematous pyelonephritis: time for a management plan with an evidence-based approach.
      Our patient presented a bubbly and mottled gas pattern in the left upper abdomen on chest X-ray, which indicated an abdominal condition; however, the patient was vagrant and had no complaints of abdominal or flank pain, which made the diagnosis challenging. Severe EPN is associated with a high mortality. Therefore, early diagnosis and more aggressive treatment can increase the survival rate.

      Ethics approval

      The study was approved by the Ethics Review Board of our institution.

      Declaration of Competing Interest

      There are no conflicts of interest to declare.

      Source of funding

      This research received no external funding.

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