- Email: [email protected]
Emphysematous pyelonephritis: fatal outcome during percutaneous drainage
European Journal of Radiology 26 (1998) 287 – 289
Case report
Emphysematous pyelonephritis: fatal outcome during percutaneous drainage Sergin Akpek *, Tayfun Turgut, Hakan O8 zdemir, Erhan T. Ilgit, Sedat Is¸ik Department of Radiology, School of Medicine, Gazi Uni6ersity, 06510 Bese6ler, Ankara, Turkey Received 3 December 1996; received in revised form 6 February 1997; accepted 7 February 1997
Keywords: Nephritis; Interventional procedures; Complications
1. Introduction Emphysematous pyelonephritis (EPN) has been defined as an acute, severe, necrotizing infection of the renal parenchyma and perirenal tissue, which results in the presence of gas within the renal parenchyma, collecting system, or perinephric tissue [1,2]. This clinical entity is highly associated with insulin dependent diabetes mellitus and usually seen in females [1 – 3]. Eschericia coli is the most commonly reported organism but Proteus, Pseudomonas, Klebsiella and mixed bacterial flora have also been implicated. Although plain radiography and ultrasonography can be diagnostic, computed tomography by allowing optimal detection and delineation of the extent of the emphysematous process, is accepted as gold standard examination in EPN. Mortality rates for EPN although declining in recent reports are between 7 – 78% depending on the applied therapeutic modality [1,2]. Medical treatment alone carries the highest mortality risk while the approach consisting of early nephrectomy and/or surgical drainage combined with broad spectrum antibiotics reported to have the lowest [2,4,5]. In addition to this approach, recent advent of interventional radiological procedures has allowed successful treatment of EPN using a percutaneous drainage (PD) procedure [3,5,6]. This technique is advocated and usually performed in * Corresponding author: Present address: Karli Sokak 62/3, Gaziosmanpasa 06700, Ankara, Turkey; Tel.: + 90 312 4364065; fax: +90 312 4464951; e-mail: [email protected]
the critically ill high risk patient group. We report a case with right sided EPN in whom the percutaneous drainage attempt resulted in fatality.
2. Case report A 58 year old woman with a history of insulin dependent diabetes mellitus presented to the emergency service with right sided flank pain, fever, shaking chills, nausea and dysuria for nearly 24 h. For the last couple of hours before the admission, progressive change of level of consciousness was also noticed by her relatives. In the emergency room she was sleepy but arousable, orientation was partially impaired, blood pressure was 110/75 mmHg, pulse rate 103/min and body temperature was 38.5°C. Laboratory data revealed a white blood cell count of 17 000/mm3, hemoglobin 12.5 mg/ dl, blood glucose 348 mg/dl, serum creatinine 1.1 mg/dl. Urinalysis revealed glucosuria, proteinuria, ketonuria and pyuria. A gas-containing mass obliterating the right psoas shadow was noted on the plain abdominal film (Fig. 1). Right kidney could not be visualized on abdominal ultrasonography. There was diffuse echogenic appearance with an acoustic shadow at right renal fossa. Abdominal CT was immediately obtained with a high suspicion of EPN. CT without intravenous contrast material demonstrated enlargement and wide spread destruction of the right kidney with multiloculated gas and pus accumulation (Fig. 2). The patient was put empirically on broad spectrum antibiotics (Sul-
0720-048X/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 7 2 0 - 0 4 8 X ( 9 7 ) 0 1 1 7 7 - 7
288
S. Akpek et al. / European Journal of Radiology 26 (1998) 287–289
baGtam-Ampicilline and Ciprofloxacin), insulin and fluid therapy. On the second post antibiotic day there was no improvement in the patient’s condition and she was classified as an grade IV anesthetic risk, according to the classification of the American Society of Anesthesiologists, and PD was attempted. Initial puncture was performed with an 18 gauge needle and 150 ml of blood tinged viscous purulent material was aspirated. Immediately after a 12 F sump catheter (MediTech, Watertown, MA) was placed, the patient’s systolic blood pressure suddenly decreased to 60 mmHg and, unfortunately, cardiopulmonary arrest ensued. She was intubated and normal sinus rhythm was established after vigorous cardiopulmonary resuscitation but systolic blood pressure remained between 40 – 50 mmHg. During her transport to the intensive care unit, a second cardiac arrest occurred and she succumbed. Cultures of the pus grew Eschericia coli. Her relatives rejected a post mortem study.
3. Discussion Since the first case report ‘Pneumaturia’ reported in 1892 by Kelly et al. [7] approximately 200 cases have been reported in medical literature. Despite the experience of more than a century, controversy on pathophysiology of EPN still remains. High blood and tissue glucose levels, decreased tissue perfusion, defective host defense mechanism and urinary tract obstruction are the major underlying factors that facilitate development of EPN. Resultant low tissue oxygen tension induces anerobic metabolism. Facultative anaerobic bacteria
Fig. 1. Large gas containing mass in right renal fossa obliterating the right psoas shadow is evident on plain abdominal radiography.
Fig. 2. Computed tomographic scan of upper abdomen without contrast material shows enlarged and completely destructed right kidney with gas accumulation.
such as Escherichia coli and Proteus mirabilis are than able to ferment glucose [4,8]. Gas chromatographic studies revealed that gas bubbles in EPN contain hydrogen, carbon dioxide, nitrogen and oxygen in different ratios. These results tend to implicate mixed acid fermentation of glucose as the pathway by which emphysematous infection develops [9]. Another controversial point is the therapeutic approach to patients with EPN. Most investigators agree that a combined approach of early nephrectomy with medical therapy is the preferred management. With this approach mortality rates have been reduced significantly [2]. The remaining group of patients are generally the ones that are critically ill and surgical methods such as nephrectomy can not be applied. Although nephrectomy has been advocated as the treatment of choice, the recent advent of interventional radiological procedures has allowed successful treatment of these critically ill patients. Another indication for PD procedure appears to be focal renal involvement or formation of a welldefined renal or perirenal abscess formation. Percutaneous drainage is very important in such patients with perinephric abscess to prevent uncontrollable spread of the infection within the perirenal space and it’s unusual continuations such as pelvis and mediastinum [10]. In a very recent comprehensive study two different and radiologically identifiable subtypes of EPN were proposed [1]. Type I EPN was characterized by parenchymal destruction with either absence of fluid collection or presence of streaky or mottled gas. In type II EPN either renal or perirenal fluid collection with bubbly or loculated gas or gas in the collecting system were typical findings. According to this definition our case was a type I EPN. Mortality rate for type I EPN was significantly higher than for the type II EPN (69 versus 18%). The authors also postulated that emergency nephrectomy was the suggested method of treatment
S. Akpek et al. / European Journal of Radiology 26 (1998) 287–289
for type I EPN, whereas PD and/or nephrostomy could be attempted primarily in type II EPN. There is no study in the literature revealing the success rate for the PD method in patients with EPN. In our review of the literature in 19 cases PD or nephrostomy was attempted as a therapeutic approach combined with medical therapy [3,5,6,11 – 20]. In two of them bilateral drainage was performed. In ten attempts PD was successful and outcomes were reported to be good. The remaining 11 attempts of PD were unsuccessful and followed by surgical procedure and/or supportive medical therapy. Five of the cases in this group had a fatal outcome [12,13,16,19]. No intraprocedural mortality was reported before. The low success rate of PD in patients with EPN (10/21, 48%) derives from the special features of this patient group. Most of them are critically ill having sepsis, disseminated intravascular coagulation or cardiovascular collapse. PD is usually decided on as the last chance for the patient since the risk of anesthesia is very high. In our opinion the risk of mortality in PD can be as high as the surgical intervention risk. The relationship between fatal outcome and the drainage procedure may be explained in terms of the procedure having triggered the acute septic shock. The interventional radiologist should be very cautious in attempting to PD or should even postpone the procedure in critically ill patients with EPN until the general status improves with supportive medical therapy. Diffuse necrosis without well-defined fluid collection or abscess (EPN type I) should be accepted as a poor prognostic indicator and nephrectomy instead of PD should be tried first in this patient group.
References [1] Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: Correlation between imaging findings and clinical outcome. Radiology 1996; 198: 433–438. [2] Michaeli J, Mogle S, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol 1984; 131: 203–207.
.
289
[3] Shahatto N, al Awadhi NZ, Ghazali S. Emphysematous pyelonephritis: Surgical implications. Br J Urol 1990; 66: 572– 574. [4] Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5-year experience with 13 patients. J Urol 1985; 134: 1086 – 1088. [5] Hudson MA, Weyman PJ, van der Vleit AH, Catalona WJ. Emphysematous pyelonephritis: Successful management by percutaneous drainage. J Urol 1986; 136: 884 – 886. [6] Hall JR, Choa RG, Wells IP. Percutaneous drainage in emphysematous pyelonephritis: An alternative to major surgery. Clin Radiol 1988; 39: 622 – 624. [7] Kelly HA, MacCallum WG. Pneumaturia. JAMA 1898; 31: 375 – 381. [8] Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med 1968; 44: 134 – 137. [9] Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol 1991; 146: 148 – 151. [10] Akpek S, Ilgit ET, Arac¸ M, O8 zdemir H, Atilla S, Is¸ık S. Bilateral perirenal urinoma with mediastinal extention. Abdom Imaging 1995; 20: 267 – 269. [11] Corr J, Gleeson M, Wilson G, Grainger R. Percutaneous management of emphysematous pyelonephritis. Br J Urol 1993; 71: 487 – 488. [12] Koh KBH, Lam HS, Lee SH. Emphysematous pyelonephritis: Drainage or nephrectomy. Br J Urol 1993; 71: 609 – 611. [13] Huang JJ, Chen KW, Ruaan MK, Tsai HM. Recurrent emphysematous pyelonephritis. A case report. Intern Urol Nephrol 1994; 26: 389 – 393. [14] Lowe BA, Poage MD. Bilateral emphysematous pyelonephritis. Urology 1991; 37: 229232. [15] Mancini R, Nani MT, Piperno GC. Percutaneous drainage in renal emphysema. Clinical case. Arch Ital Urol Nefrol Androl 1992; 64: 123 – 126. [16] Andersen JB, Olsen AD, Pedersen HM. Fatal emphysematous pyelonephritis. Ugeskr Laeger 1992; 154: 1432 – 1433. [17] Egawa S, Utsunomia T, Uchida T, Mashimo S, Koshiba K. Emphysematous pyelonephritis, ureteritis, and cystitis in a diabetic patient. Urol Int 1994; 52: 176 – 178. [18] Rosado J, Fernandes AP, Aleluia C, et al. Emphysematous pyelonephritis. Acta Med Port 1993; 6: 271 – 274. [19] Bahloul A, Jemel S, Koubaa A, Letaief Y, Mhiri MN. Emphysematous pyelonephritis. Apropos of 4 cases. Prog Urol 1993; 3: 803 – 811. [20] Paivansalo M, Hellstrom P, Siniluoto T, Leinonen A. Emphysematous pyelonephritis. Radiologic and clinical findings in six cases. Acta Radiol 1989; 30: 311 – 315.
Case report
Emphysematous pyelonephritis: fatal outcome during percutaneous drainage Sergin Akpek *, Tayfun Turgut, Hakan O8 zdemir, Erhan T. Ilgit, Sedat Is¸ik Department of Radiology, School of Medicine, Gazi Uni6ersity, 06510 Bese6ler, Ankara, Turkey Received 3 December 1996; received in revised form 6 February 1997; accepted 7 February 1997
Keywords: Nephritis; Interventional procedures; Complications
1. Introduction Emphysematous pyelonephritis (EPN) has been defined as an acute, severe, necrotizing infection of the renal parenchyma and perirenal tissue, which results in the presence of gas within the renal parenchyma, collecting system, or perinephric tissue [1,2]. This clinical entity is highly associated with insulin dependent diabetes mellitus and usually seen in females [1 – 3]. Eschericia coli is the most commonly reported organism but Proteus, Pseudomonas, Klebsiella and mixed bacterial flora have also been implicated. Although plain radiography and ultrasonography can be diagnostic, computed tomography by allowing optimal detection and delineation of the extent of the emphysematous process, is accepted as gold standard examination in EPN. Mortality rates for EPN although declining in recent reports are between 7 – 78% depending on the applied therapeutic modality [1,2]. Medical treatment alone carries the highest mortality risk while the approach consisting of early nephrectomy and/or surgical drainage combined with broad spectrum antibiotics reported to have the lowest [2,4,5]. In addition to this approach, recent advent of interventional radiological procedures has allowed successful treatment of EPN using a percutaneous drainage (PD) procedure [3,5,6]. This technique is advocated and usually performed in * Corresponding author: Present address: Karli Sokak 62/3, Gaziosmanpasa 06700, Ankara, Turkey; Tel.: + 90 312 4364065; fax: +90 312 4464951; e-mail: [email protected]
the critically ill high risk patient group. We report a case with right sided EPN in whom the percutaneous drainage attempt resulted in fatality.
2. Case report A 58 year old woman with a history of insulin dependent diabetes mellitus presented to the emergency service with right sided flank pain, fever, shaking chills, nausea and dysuria for nearly 24 h. For the last couple of hours before the admission, progressive change of level of consciousness was also noticed by her relatives. In the emergency room she was sleepy but arousable, orientation was partially impaired, blood pressure was 110/75 mmHg, pulse rate 103/min and body temperature was 38.5°C. Laboratory data revealed a white blood cell count of 17 000/mm3, hemoglobin 12.5 mg/ dl, blood glucose 348 mg/dl, serum creatinine 1.1 mg/dl. Urinalysis revealed glucosuria, proteinuria, ketonuria and pyuria. A gas-containing mass obliterating the right psoas shadow was noted on the plain abdominal film (Fig. 1). Right kidney could not be visualized on abdominal ultrasonography. There was diffuse echogenic appearance with an acoustic shadow at right renal fossa. Abdominal CT was immediately obtained with a high suspicion of EPN. CT without intravenous contrast material demonstrated enlargement and wide spread destruction of the right kidney with multiloculated gas and pus accumulation (Fig. 2). The patient was put empirically on broad spectrum antibiotics (Sul-
0720-048X/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 7 2 0 - 0 4 8 X ( 9 7 ) 0 1 1 7 7 - 7
288
S. Akpek et al. / European Journal of Radiology 26 (1998) 287–289
baGtam-Ampicilline and Ciprofloxacin), insulin and fluid therapy. On the second post antibiotic day there was no improvement in the patient’s condition and she was classified as an grade IV anesthetic risk, according to the classification of the American Society of Anesthesiologists, and PD was attempted. Initial puncture was performed with an 18 gauge needle and 150 ml of blood tinged viscous purulent material was aspirated. Immediately after a 12 F sump catheter (MediTech, Watertown, MA) was placed, the patient’s systolic blood pressure suddenly decreased to 60 mmHg and, unfortunately, cardiopulmonary arrest ensued. She was intubated and normal sinus rhythm was established after vigorous cardiopulmonary resuscitation but systolic blood pressure remained between 40 – 50 mmHg. During her transport to the intensive care unit, a second cardiac arrest occurred and she succumbed. Cultures of the pus grew Eschericia coli. Her relatives rejected a post mortem study.
3. Discussion Since the first case report ‘Pneumaturia’ reported in 1892 by Kelly et al. [7] approximately 200 cases have been reported in medical literature. Despite the experience of more than a century, controversy on pathophysiology of EPN still remains. High blood and tissue glucose levels, decreased tissue perfusion, defective host defense mechanism and urinary tract obstruction are the major underlying factors that facilitate development of EPN. Resultant low tissue oxygen tension induces anerobic metabolism. Facultative anaerobic bacteria
Fig. 1. Large gas containing mass in right renal fossa obliterating the right psoas shadow is evident on plain abdominal radiography.
Fig. 2. Computed tomographic scan of upper abdomen without contrast material shows enlarged and completely destructed right kidney with gas accumulation.
such as Escherichia coli and Proteus mirabilis are than able to ferment glucose [4,8]. Gas chromatographic studies revealed that gas bubbles in EPN contain hydrogen, carbon dioxide, nitrogen and oxygen in different ratios. These results tend to implicate mixed acid fermentation of glucose as the pathway by which emphysematous infection develops [9]. Another controversial point is the therapeutic approach to patients with EPN. Most investigators agree that a combined approach of early nephrectomy with medical therapy is the preferred management. With this approach mortality rates have been reduced significantly [2]. The remaining group of patients are generally the ones that are critically ill and surgical methods such as nephrectomy can not be applied. Although nephrectomy has been advocated as the treatment of choice, the recent advent of interventional radiological procedures has allowed successful treatment of these critically ill patients. Another indication for PD procedure appears to be focal renal involvement or formation of a welldefined renal or perirenal abscess formation. Percutaneous drainage is very important in such patients with perinephric abscess to prevent uncontrollable spread of the infection within the perirenal space and it’s unusual continuations such as pelvis and mediastinum [10]. In a very recent comprehensive study two different and radiologically identifiable subtypes of EPN were proposed [1]. Type I EPN was characterized by parenchymal destruction with either absence of fluid collection or presence of streaky or mottled gas. In type II EPN either renal or perirenal fluid collection with bubbly or loculated gas or gas in the collecting system were typical findings. According to this definition our case was a type I EPN. Mortality rate for type I EPN was significantly higher than for the type II EPN (69 versus 18%). The authors also postulated that emergency nephrectomy was the suggested method of treatment
S. Akpek et al. / European Journal of Radiology 26 (1998) 287–289
for type I EPN, whereas PD and/or nephrostomy could be attempted primarily in type II EPN. There is no study in the literature revealing the success rate for the PD method in patients with EPN. In our review of the literature in 19 cases PD or nephrostomy was attempted as a therapeutic approach combined with medical therapy [3,5,6,11 – 20]. In two of them bilateral drainage was performed. In ten attempts PD was successful and outcomes were reported to be good. The remaining 11 attempts of PD were unsuccessful and followed by surgical procedure and/or supportive medical therapy. Five of the cases in this group had a fatal outcome [12,13,16,19]. No intraprocedural mortality was reported before. The low success rate of PD in patients with EPN (10/21, 48%) derives from the special features of this patient group. Most of them are critically ill having sepsis, disseminated intravascular coagulation or cardiovascular collapse. PD is usually decided on as the last chance for the patient since the risk of anesthesia is very high. In our opinion the risk of mortality in PD can be as high as the surgical intervention risk. The relationship between fatal outcome and the drainage procedure may be explained in terms of the procedure having triggered the acute septic shock. The interventional radiologist should be very cautious in attempting to PD or should even postpone the procedure in critically ill patients with EPN until the general status improves with supportive medical therapy. Diffuse necrosis without well-defined fluid collection or abscess (EPN type I) should be accepted as a poor prognostic indicator and nephrectomy instead of PD should be tried first in this patient group.
References [1] Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: Correlation between imaging findings and clinical outcome. Radiology 1996; 198: 433–438. [2] Michaeli J, Mogle S, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol 1984; 131: 203–207.
.
289
[3] Shahatto N, al Awadhi NZ, Ghazali S. Emphysematous pyelonephritis: Surgical implications. Br J Urol 1990; 66: 572– 574. [4] Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5-year experience with 13 patients. J Urol 1985; 134: 1086 – 1088. [5] Hudson MA, Weyman PJ, van der Vleit AH, Catalona WJ. Emphysematous pyelonephritis: Successful management by percutaneous drainage. J Urol 1986; 136: 884 – 886. [6] Hall JR, Choa RG, Wells IP. Percutaneous drainage in emphysematous pyelonephritis: An alternative to major surgery. Clin Radiol 1988; 39: 622 – 624. [7] Kelly HA, MacCallum WG. Pneumaturia. JAMA 1898; 31: 375 – 381. [8] Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis. A new case and review of previous observations. Am J Med 1968; 44: 134 – 137. [9] Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol 1991; 146: 148 – 151. [10] Akpek S, Ilgit ET, Arac¸ M, O8 zdemir H, Atilla S, Is¸ık S. Bilateral perirenal urinoma with mediastinal extention. Abdom Imaging 1995; 20: 267 – 269. [11] Corr J, Gleeson M, Wilson G, Grainger R. Percutaneous management of emphysematous pyelonephritis. Br J Urol 1993; 71: 487 – 488. [12] Koh KBH, Lam HS, Lee SH. Emphysematous pyelonephritis: Drainage or nephrectomy. Br J Urol 1993; 71: 609 – 611. [13] Huang JJ, Chen KW, Ruaan MK, Tsai HM. Recurrent emphysematous pyelonephritis. A case report. Intern Urol Nephrol 1994; 26: 389 – 393. [14] Lowe BA, Poage MD. Bilateral emphysematous pyelonephritis. Urology 1991; 37: 229232. [15] Mancini R, Nani MT, Piperno GC. Percutaneous drainage in renal emphysema. Clinical case. Arch Ital Urol Nefrol Androl 1992; 64: 123 – 126. [16] Andersen JB, Olsen AD, Pedersen HM. Fatal emphysematous pyelonephritis. Ugeskr Laeger 1992; 154: 1432 – 1433. [17] Egawa S, Utsunomia T, Uchida T, Mashimo S, Koshiba K. Emphysematous pyelonephritis, ureteritis, and cystitis in a diabetic patient. Urol Int 1994; 52: 176 – 178. [18] Rosado J, Fernandes AP, Aleluia C, et al. Emphysematous pyelonephritis. Acta Med Port 1993; 6: 271 – 274. [19] Bahloul A, Jemel S, Koubaa A, Letaief Y, Mhiri MN. Emphysematous pyelonephritis. Apropos of 4 cases. Prog Urol 1993; 3: 803 – 811. [20] Paivansalo M, Hellstrom P, Siniluoto T, Leinonen A. Emphysematous pyelonephritis. Radiologic and clinical findings in six cases. Acta Radiol 1989; 30: 311 – 315.