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Emphysematous Pyelonephritis in a Renal Allograft
The Journal of Emergency Medicine, Vol. 43, No. 6, pp. e485–e486, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.06.048
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS PYELONEPHRITIS IN A RENAL ALLOGRAFT Yuh-Feng Tsai, MD,*† Chin-Chu Wu, MD,‡ and Aming Chor-Ming Lin, MS, MD,†‡ *Department of Medical Imaging, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, †School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan, and ‡Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Reprint Address: Aming Chor-Ming Lin, MS, MD, Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Road, Shih Lin, Taipei, Taiwan
demonstrated numerous WBC and Gram-negative bacilli. He underwent fluid resuscitation and was given oxygen supplement. An emergency computed tomography (CT) scan of the abdomen revealed diffuse parenchymal destruction of the kidney allograft with extensive mottled gas (Figure 1). He was intubated, admitted to the intensive care unit, and given antibiotics. The patient died 7 h after hospitalization. Blood and urine cultures grew Escherichia coli.
INTRODUCTION Emphysematous pyelonephritis (EPN) is rare, but the frequency is higher in diabetics and immunocompromised patients. We describe a case of EPN occurring in a patient who underwent renal transplantation due to diabetes nephropathy with end-stage renal disease. CASE REPORT A 46-year-old man presented to the Emergency Department after having fever and chills for 2 days. He had a history of renal transplantation for diabetic nephropathy. After renal transplantation he regularly received immunosuppressive therapy, including tacrolimus, mycophenolate mofetil, and prednisolone, for 1 year before presentation. On arrival, his blood pressure was 68/40 mm Hg, with a heart rate of 110 beats/min and a respiratory rate of 30 breaths/min. The physical examination showed a temperature of 40 C (104 F), a distended abdomen, and hypoactive bowel sounds; with mild tenderness in the right lower quadrants. The laboratory evaluation revealed a white blood cell (WBC) count of 16,800/mm3 with 85% segmented neutrophils, C-reactive protein of 38 mg/L, glucose 240 mg/dL, serum urea nitrogen 80 mg/dL, serum creatinine 2.8 mg/dL, sodium 138 mEq/L, potassium 6.7 mEq/L, and hemoglobin 9.8 gm/dL. Arterial blood gas on room air revealed pH 7.12, PCO2 28 mm Hg, PO2 62 mm Hg, and HCO3 12.4 mmol/L. Urine analysis
DISCUSSION EPN is a severe form of acute pyelonephritis and is rarely reported in renal allografts (1). Acute pyelonephritis is a clinical diagnosis, based on the signs and symptoms of flank pain, tenderness, and fever. Laboratory findings are leukocytosis, pyuria, and positive urine culture. Escherichia coli and Klebsiella pneumoniae are the most common pathogens (2). Emphysematous urinary tract infection is infection of the lower or upper urinary tract associated with gas formation. EPN is an acute lifethreatening bacterial infection, a gas-forming necrotizing bacterial infection in renal parenchyma, collecting system, or perinephric tissue. Most cases are associated with patients with uncontrolled diabetes mellitus, urinary tract obstruction, and immunosuppression resulting from renal transplantation, requiring early diagnosis and intervention to reduce morbidity and mortality (3). Complicated urinary tract infection may occur in patients after renal
RECEIVED: 17 January 2011; FINAL SUBMISSION RECEIVED: 2 May 2011; ACCEPTED: 5 June 2011 e485
e486
Y.-F. Tsai et al.
presentations of graft emphysematous infection include localized pain and tenderness at the transplant site, oliguria, and systemic inflammatory response syndrome. CT should be performed without delay in severe sepsis, high-risk patients who have evidence of EPN, for more efficient early diagnosis and consequently, treatment of percutaneous renal drainage or nephrectomy. Surgical intervention is necessary in patients without prompt response to combined broad-spectrum antibacterial therapy and percutaneous renal drainage. However, nephrectomy is not feasible in the critically ill patients due to high-risk of general anesthesia and high mortality rate is observed in this group of patients (4). Figure 1. Emphysematous pyelonephritis: computed tomography scan of the abdomen showing abnormal gas collection in the renal allograft (arrows).
REFERENCES transplantation. The symptoms may be subtle in patients on corticosteroid and immunosuppressive therapy. Diagnosis of this condition is usually made on clinical and radiological grounds. CT is the most sensitive and efficient tool for detecting subtle gas shadows and destruction in the renal parenchyma, collecting system, and perinephric tissue. CT scanning demonstrates comprehensive anatomic and pathologic information that accurately characterizes the extent and location of the gas collection and necrosis. In addition, CT scanning eliminates the artifacts seen with conventional imaging methods. Clinical
1. Al-Geizawi SM, Farney AC, Rogers J, et al. Renal allograft failure due to emphysematous pyelonephritis: successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543–50. 2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis and pathogenesis. Arch Intern Med 2000;160:797–805. 3. Wang JM, Lim HK, Pang KK. Emphysematous pyelonephritis. Scand J Urol Nephrol 2007;41:223–9. 4. Chan PH, Kho VKS, Lai SK, et al. Treatment of emphysematous pyelonephritis with broad-spectrum antibacterials and percutaneous renal drainage: an analysis of 10 patients. J Chin Med Assoc 2005; 68:29–32.
doi:10.1016/j.jemermed.2011.06.048
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS PYELONEPHRITIS IN A RENAL ALLOGRAFT Yuh-Feng Tsai, MD,*† Chin-Chu Wu, MD,‡ and Aming Chor-Ming Lin, MS, MD,†‡ *Department of Medical Imaging, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, †School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan, and ‡Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Reprint Address: Aming Chor-Ming Lin, MS, MD, Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Road, Shih Lin, Taipei, Taiwan
demonstrated numerous WBC and Gram-negative bacilli. He underwent fluid resuscitation and was given oxygen supplement. An emergency computed tomography (CT) scan of the abdomen revealed diffuse parenchymal destruction of the kidney allograft with extensive mottled gas (Figure 1). He was intubated, admitted to the intensive care unit, and given antibiotics. The patient died 7 h after hospitalization. Blood and urine cultures grew Escherichia coli.
INTRODUCTION Emphysematous pyelonephritis (EPN) is rare, but the frequency is higher in diabetics and immunocompromised patients. We describe a case of EPN occurring in a patient who underwent renal transplantation due to diabetes nephropathy with end-stage renal disease. CASE REPORT A 46-year-old man presented to the Emergency Department after having fever and chills for 2 days. He had a history of renal transplantation for diabetic nephropathy. After renal transplantation he regularly received immunosuppressive therapy, including tacrolimus, mycophenolate mofetil, and prednisolone, for 1 year before presentation. On arrival, his blood pressure was 68/40 mm Hg, with a heart rate of 110 beats/min and a respiratory rate of 30 breaths/min. The physical examination showed a temperature of 40 C (104 F), a distended abdomen, and hypoactive bowel sounds; with mild tenderness in the right lower quadrants. The laboratory evaluation revealed a white blood cell (WBC) count of 16,800/mm3 with 85% segmented neutrophils, C-reactive protein of 38 mg/L, glucose 240 mg/dL, serum urea nitrogen 80 mg/dL, serum creatinine 2.8 mg/dL, sodium 138 mEq/L, potassium 6.7 mEq/L, and hemoglobin 9.8 gm/dL. Arterial blood gas on room air revealed pH 7.12, PCO2 28 mm Hg, PO2 62 mm Hg, and HCO3 12.4 mmol/L. Urine analysis
DISCUSSION EPN is a severe form of acute pyelonephritis and is rarely reported in renal allografts (1). Acute pyelonephritis is a clinical diagnosis, based on the signs and symptoms of flank pain, tenderness, and fever. Laboratory findings are leukocytosis, pyuria, and positive urine culture. Escherichia coli and Klebsiella pneumoniae are the most common pathogens (2). Emphysematous urinary tract infection is infection of the lower or upper urinary tract associated with gas formation. EPN is an acute lifethreatening bacterial infection, a gas-forming necrotizing bacterial infection in renal parenchyma, collecting system, or perinephric tissue. Most cases are associated with patients with uncontrolled diabetes mellitus, urinary tract obstruction, and immunosuppression resulting from renal transplantation, requiring early diagnosis and intervention to reduce morbidity and mortality (3). Complicated urinary tract infection may occur in patients after renal
RECEIVED: 17 January 2011; FINAL SUBMISSION RECEIVED: 2 May 2011; ACCEPTED: 5 June 2011 e485
e486
Y.-F. Tsai et al.
presentations of graft emphysematous infection include localized pain and tenderness at the transplant site, oliguria, and systemic inflammatory response syndrome. CT should be performed without delay in severe sepsis, high-risk patients who have evidence of EPN, for more efficient early diagnosis and consequently, treatment of percutaneous renal drainage or nephrectomy. Surgical intervention is necessary in patients without prompt response to combined broad-spectrum antibacterial therapy and percutaneous renal drainage. However, nephrectomy is not feasible in the critically ill patients due to high-risk of general anesthesia and high mortality rate is observed in this group of patients (4). Figure 1. Emphysematous pyelonephritis: computed tomography scan of the abdomen showing abnormal gas collection in the renal allograft (arrows).
REFERENCES transplantation. The symptoms may be subtle in patients on corticosteroid and immunosuppressive therapy. Diagnosis of this condition is usually made on clinical and radiological grounds. CT is the most sensitive and efficient tool for detecting subtle gas shadows and destruction in the renal parenchyma, collecting system, and perinephric tissue. CT scanning demonstrates comprehensive anatomic and pathologic information that accurately characterizes the extent and location of the gas collection and necrosis. In addition, CT scanning eliminates the artifacts seen with conventional imaging methods. Clinical
1. Al-Geizawi SM, Farney AC, Rogers J, et al. Renal allograft failure due to emphysematous pyelonephritis: successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543–50. 2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis and pathogenesis. Arch Intern Med 2000;160:797–805. 3. Wang JM, Lim HK, Pang KK. Emphysematous pyelonephritis. Scand J Urol Nephrol 2007;41:223–9. 4. Chan PH, Kho VKS, Lai SK, et al. Treatment of emphysematous pyelonephritis with broad-spectrum antibacterials and percutaneous renal drainage: an analysis of 10 patients. J Chin Med Assoc 2005; 68:29–32.