Emphysematous pyelonephritis in a patient with chronic pancreatitis and diabetes

A 57-year-old man with diabetes and chronic pancreatitis presented to the emergency department with a 3-day history of tachypnea and abdominal distension. His heart rate was 120 beats per minute and blood pressure was 95/55 mmHg. Physical examination revealed tenderness in the right kidney area. Initial laboratory tests showed that the white-cell count was 33.41 × 10⁹/L (reference range, 3.5 to 9.5 10⁹/L), serum creatinine level was 632 umol/L (reference range, 68 to 108 umol/L), and blood PH level was 7.149 (reference range, 7.35 to 7.45). Glycated hemoglobin (HbA1c) value was 12.2% (Reference value: 4.5%-6.1%). A computed tomographic (CT) scan of the abdomen showed a large area of gas in the right kidney area, ureter and bladder, a finding suggestive of emphysematous pyelonephritis (Figure A). Treatment with glycemic control, intravenous fluid, broad-spectrum antibiotics (imipenem) and continuous renal replacement therapy were initiated, and the patient was admitted to the medical intensive care unit (ICU). A percutaneous renal drain was then inserted. Blood, urine, and drainage fluid cultures grew Escherichia coli. Through continued treatment in the ICU, the patient's condition gradually improved, and he was discharged on the 31st day of hospitalization. After 4 and 8 weeks of drug treatment, repeat CT showed that the renal pneuma was gradually absorbed, and the renal parenchyma also appeared on enhanced scanning (Figure B, 4 weeks, and C, 8 weeks).