- Email: [email protected]
Emphysematous Pyelonephritis with Emphysematous Pancreatitis
The Journal of Emergency Medicine, Vol. 39, No. 1, pp. e85– e87, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2007.11.071
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS PYELONEPHRITIS WITH EMPHYSEMATOUS PANCREATITIS Kushaljit Singh Sodhi,
MD,*
Anupam Lal, MD,* Sameer Vyas, N. Khandelwal, MD, DNB, FICR*
MD,*
S. Verma,
MD,†
and
*Department of Radiodiagnosis and †Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India Reprint Address: Kushaljit Singh Sodhi, MD, Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India
INTRODUCTION
Clinical examination revealed tenderness and mild swelling in the left lumbar region. She had a pulse rate of 128 beats/min, respiratory rate 36 breaths/min, and blood pressure 130/90 mm Hg. Laboratory investigation revealed: blood urea 40 mg%, serum creatinine 1.2 mg%, bilirubin (0.7 mg), serum glutamic oxaloacetic transaminase (15 IU), and serum glutamic pyruvic transaminase (14 IU), all of which were within normal limits. Blood glucose levels were 204 mg%. Blood culture showed growth of Escherichia coli. Computed tomography (CT) scan of the abdomen was done, which showed a large gaseous collection (Figures 1, 2) replacing the left kidney, with minimal fluid present in the left renal fossa and perinephric space. The fluid extended inferiorly to the left hemi-pelvis and iliac fossa and superiorly was seen to extend to the anterior pararenal space, with involvement of the pancreatic body and tail as well. It was seen to involve the anterior, posterior, and lateral abdominal walls, with extensive subcutaneous air pockets in the muscles. The right kidney was normal. Based on the CT scan, a diagnosis of extensive emphysematous pyelonephritis with emphysematous pancreatitis was made. The patient was treated with intravenous saline, Amikacin (aminoglycoside antibiotic), Oframax (ceftriaxone sodium), Metrogyl (metronidazole), and regular insulin. Subsequently, she underwent pigtail catheter drainage. She became afebrile, with controlled glucose levels under further observation.
Emphysematous pyelonephritis (EPN) is a rare, fulminant gas-forming infection of the renal parenchyma that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue (1). EPN occurs typically (⬎ 90%) in diabetic patients. However, it is also seen in non-diabetic patients with obstruction of the renal or ureteric system (2). Diagnosis of EPN is based on radiological confirmation of gas within the kidney or collecting system. It has a high mortality rate and needs early emergency management. Milder forms of the disease are managed successfully with a combination of antibiotics and percutaneous drainage. However, early nephrectomy is recommended in more severe cases or in patients with septic shock. Our case was unusual in that there was involvement of both kidneys and the pancreas, resulting in emphysematous pyelonephritis and pancreatitis.
CASE REPORT A 55-year-old woman who had type 2 diabetes mellitus (DM) for the past 4 years presented with a 2-week history of fever and left-sided abdominal pain. Fever was high, intermittent, and without any chills/rigor. She had pain in the left lumbar and flank region, which was associated with swelling. There was no history of trauma.
RECEIVED: 12 January 2007; FINAL ACCEPTED: 8 November 2007
SUBMISSION RECEIVED:
29 June 2007; e85
e86
K. S. Sodhi et al.
Figure 1. Computed tomography scan of the abdomen shows extensive gas replacing the left kidney (thick arrow). The right kidney (thin arrow) is normal. Extension to the pancreas is marked by multiple long arrows. Note air in the lateral and posterior abdominal walls.
DISCUSSION Emphysematous pyelonephritis represents a severe lifethreatening infection of the renal parenchyma with gasforming bacteria. Underlying poorly controlled diabetes mellitis is present in up to 90% of patients who develop emphysematous pyelonephritis (3). Urinary collecting system obstructions from pathologic conditions such as stone disease, sloughed papilla, or urothelial neoplasm are also commonly present (3). The most common clinical manifestations of EPN are non-specific (i.e., fever, flank pain, and pyuria) and might not be different from the classic triad of upper UTI (urinary tract infection). However, thrombocytopenia (46%), acute renal function impairment (35%), disturbance of consciousness (19%), and shock (29%) can be the initial presentations, especially in severe cases or in patients not given an early diagnosis and management of EPN (1). Emphysematous pyelonephritis carries an overall mortality rate of approximately 50% (3,4). Escherichia coli or Klebsiella pneumoniae infection in patients with DM or urinary tract obstruction is the cornerstone for the development of EPN. In patients with DM, the high level of blood glucose may provide certain micro-organisms with a more favorable environment for gas formation via mixed acid fermentation of glucose (1). The diagnosis of EPN is classically made by demonstrating gas in the renal or perinephric tissue by plain abdominal radiograph or renal ultrasound. However, neither of these diagnostic modalities is either sensitive or specific in the detection of EPN. In contrast, CT scan can confirm the diagnosis and also show
the extent of disease to aid in identification of the source of obstruction when present. Therefore, severe manifestations or unresolving fever after antibiotic treatment in patients with upper UTI should arouse the suspicion that a serious acute renal infection, such as acute bacterial nephritis, renal abscess, or even EPN is occurring (5). Abdominal CT scan is thus important for early diagnosis and management of EPN. A CT classification scheme proposed by Wan et al. divides emphysematous pyelonephritis into two types and has prognostic significance (6). Type I emphysematous pyelonephritis is characterized by parenchymal destruction with streaky or mottled gas collections but no fluid collections. Type II is characterized by bubbly or loculated gas within the parenchyma or collecting system with associated renal or perirenal fluid collections that are thought to represent a favorable immune response. Type I emphysematous pyelonephritis has a 69% mortality rate vs. 18% for type II, although transformation from type I to type II has been observed after conservative treatment. With minimal functional impairment and localized disease (discrete abscess or focal pyelonephritis), percutaneous drainage or partial nephrectomy may be attempted, whereas poor renal function usually would be an indication for total nephrectomy (3). First-line treatment for emphysematous pyelonephritis includes aggressive fluid support, correction of electrolyte and acid-base irregularities, hyperglycemia
Figure 2. Coronal computed tomography image shows the extent of emphysematous pyelonephritis.
Emphysematous Pyelonephritis with Emphysematous Pancreatitis
control, and intravenous broad-spectrum antimicrobial therapy. Glucose control in diabetic patients is easier after nephrectomy than with conservative therapy alone (7). Patients with a fulminant clinical course, unsuccessful drainage, or failed conservative therapy should undergo nephrectomy (1,4). In non-diabetic patients, successful removal of an obstruction, surgical or percutaneous drainage, and aggressive antimicrobial management may be sufficient (1,8). Clinical indicators of poor prognosis include thrombocytopenia, acute renal function impairment, disturbance of consciousness, and shock (1,3). Emphysematous pancreatitis is an uncommon and life-threatening necrotizing infection of the pancreas. It is associated with gas-forming bacteria and is characterized by the presence of gas within the pancreatic parenchyma (9). CT, once again, is the modality of choice for detecting parenchymal gas as well as for evaluating its extent and location and evaluating potential complications, including parenchymal necrosis and abscess formation (3,10). The prognosis for emphysematous pancreatitis is grave, and successful treatment requires aggressive management of the infection with systemic antimicrobial therapy, control of septic shock, and early surgical debridement or percutaneous drainage (10).
e87
CONCLUSION Our case was unusual in that there was involvement of both kidneys and pancreas, resulting in emphysematous pyelonephritis and pancreatitis.
REFERENCES 1. Huang JJ, Tseng CC. Emphysematous pyelonephritis. Arch Intern Med 2000;160:797– 805. 2. Muttarak M, Mai WN. Clinics in diagnostic imaging (99). Left emphysematous pyelonephritis. Singapore Med J 2004;45:340 –2. 3. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543– 61. 4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol 1997;157:1569 –73. 5. Huang JJ, Sung JM, Chen KW, Ruaan MK, Shu HF, Chuang YC. Acute bacterial nephritis: a clinico-radiological correlation based on computed tomography. Am J Med 1992;93:289 –98. 6. 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– 8. 7. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735– 47. 8. Roberts JA. Management of pyelonephritis and upper urinary tract infections. Urol Clin North Am 1999;26:753– 63. 9. Ku YM, Kim HK, Cho YS, Chae HS. Medical management of emphysematous pancreatitis. J Gastroenterol Hepatol 2007;22:455– 6. 10. Daly JJ Jr, Alderman DF, Conway WF. General case of the day. Radiographics 1995;15:489 –92.
doi:10.1016/j.jemermed.2007.11.071
Visual Diagnosis in Emergency Medicine
EMPHYSEMATOUS PYELONEPHRITIS WITH EMPHYSEMATOUS PANCREATITIS Kushaljit Singh Sodhi,
MD,*
Anupam Lal, MD,* Sameer Vyas, N. Khandelwal, MD, DNB, FICR*
MD,*
S. Verma,
MD,†
and
*Department of Radiodiagnosis and †Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India Reprint Address: Kushaljit Singh Sodhi, MD, Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India
INTRODUCTION
Clinical examination revealed tenderness and mild swelling in the left lumbar region. She had a pulse rate of 128 beats/min, respiratory rate 36 breaths/min, and blood pressure 130/90 mm Hg. Laboratory investigation revealed: blood urea 40 mg%, serum creatinine 1.2 mg%, bilirubin (0.7 mg), serum glutamic oxaloacetic transaminase (15 IU), and serum glutamic pyruvic transaminase (14 IU), all of which were within normal limits. Blood glucose levels were 204 mg%. Blood culture showed growth of Escherichia coli. Computed tomography (CT) scan of the abdomen was done, which showed a large gaseous collection (Figures 1, 2) replacing the left kidney, with minimal fluid present in the left renal fossa and perinephric space. The fluid extended inferiorly to the left hemi-pelvis and iliac fossa and superiorly was seen to extend to the anterior pararenal space, with involvement of the pancreatic body and tail as well. It was seen to involve the anterior, posterior, and lateral abdominal walls, with extensive subcutaneous air pockets in the muscles. The right kidney was normal. Based on the CT scan, a diagnosis of extensive emphysematous pyelonephritis with emphysematous pancreatitis was made. The patient was treated with intravenous saline, Amikacin (aminoglycoside antibiotic), Oframax (ceftriaxone sodium), Metrogyl (metronidazole), and regular insulin. Subsequently, she underwent pigtail catheter drainage. She became afebrile, with controlled glucose levels under further observation.
Emphysematous pyelonephritis (EPN) is a rare, fulminant gas-forming infection of the renal parenchyma that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue (1). EPN occurs typically (⬎ 90%) in diabetic patients. However, it is also seen in non-diabetic patients with obstruction of the renal or ureteric system (2). Diagnosis of EPN is based on radiological confirmation of gas within the kidney or collecting system. It has a high mortality rate and needs early emergency management. Milder forms of the disease are managed successfully with a combination of antibiotics and percutaneous drainage. However, early nephrectomy is recommended in more severe cases or in patients with septic shock. Our case was unusual in that there was involvement of both kidneys and the pancreas, resulting in emphysematous pyelonephritis and pancreatitis.
CASE REPORT A 55-year-old woman who had type 2 diabetes mellitus (DM) for the past 4 years presented with a 2-week history of fever and left-sided abdominal pain. Fever was high, intermittent, and without any chills/rigor. She had pain in the left lumbar and flank region, which was associated with swelling. There was no history of trauma.
RECEIVED: 12 January 2007; FINAL ACCEPTED: 8 November 2007
SUBMISSION RECEIVED:
29 June 2007; e85
e86
K. S. Sodhi et al.
Figure 1. Computed tomography scan of the abdomen shows extensive gas replacing the left kidney (thick arrow). The right kidney (thin arrow) is normal. Extension to the pancreas is marked by multiple long arrows. Note air in the lateral and posterior abdominal walls.
DISCUSSION Emphysematous pyelonephritis represents a severe lifethreatening infection of the renal parenchyma with gasforming bacteria. Underlying poorly controlled diabetes mellitis is present in up to 90% of patients who develop emphysematous pyelonephritis (3). Urinary collecting system obstructions from pathologic conditions such as stone disease, sloughed papilla, or urothelial neoplasm are also commonly present (3). The most common clinical manifestations of EPN are non-specific (i.e., fever, flank pain, and pyuria) and might not be different from the classic triad of upper UTI (urinary tract infection). However, thrombocytopenia (46%), acute renal function impairment (35%), disturbance of consciousness (19%), and shock (29%) can be the initial presentations, especially in severe cases or in patients not given an early diagnosis and management of EPN (1). Emphysematous pyelonephritis carries an overall mortality rate of approximately 50% (3,4). Escherichia coli or Klebsiella pneumoniae infection in patients with DM or urinary tract obstruction is the cornerstone for the development of EPN. In patients with DM, the high level of blood glucose may provide certain micro-organisms with a more favorable environment for gas formation via mixed acid fermentation of glucose (1). The diagnosis of EPN is classically made by demonstrating gas in the renal or perinephric tissue by plain abdominal radiograph or renal ultrasound. However, neither of these diagnostic modalities is either sensitive or specific in the detection of EPN. In contrast, CT scan can confirm the diagnosis and also show
the extent of disease to aid in identification of the source of obstruction when present. Therefore, severe manifestations or unresolving fever after antibiotic treatment in patients with upper UTI should arouse the suspicion that a serious acute renal infection, such as acute bacterial nephritis, renal abscess, or even EPN is occurring (5). Abdominal CT scan is thus important for early diagnosis and management of EPN. A CT classification scheme proposed by Wan et al. divides emphysematous pyelonephritis into two types and has prognostic significance (6). Type I emphysematous pyelonephritis is characterized by parenchymal destruction with streaky or mottled gas collections but no fluid collections. Type II is characterized by bubbly or loculated gas within the parenchyma or collecting system with associated renal or perirenal fluid collections that are thought to represent a favorable immune response. Type I emphysematous pyelonephritis has a 69% mortality rate vs. 18% for type II, although transformation from type I to type II has been observed after conservative treatment. With minimal functional impairment and localized disease (discrete abscess or focal pyelonephritis), percutaneous drainage or partial nephrectomy may be attempted, whereas poor renal function usually would be an indication for total nephrectomy (3). First-line treatment for emphysematous pyelonephritis includes aggressive fluid support, correction of electrolyte and acid-base irregularities, hyperglycemia
Figure 2. Coronal computed tomography image shows the extent of emphysematous pyelonephritis.
Emphysematous Pyelonephritis with Emphysematous Pancreatitis
control, and intravenous broad-spectrum antimicrobial therapy. Glucose control in diabetic patients is easier after nephrectomy than with conservative therapy alone (7). Patients with a fulminant clinical course, unsuccessful drainage, or failed conservative therapy should undergo nephrectomy (1,4). In non-diabetic patients, successful removal of an obstruction, surgical or percutaneous drainage, and aggressive antimicrobial management may be sufficient (1,8). Clinical indicators of poor prognosis include thrombocytopenia, acute renal function impairment, disturbance of consciousness, and shock (1,3). Emphysematous pancreatitis is an uncommon and life-threatening necrotizing infection of the pancreas. It is associated with gas-forming bacteria and is characterized by the presence of gas within the pancreatic parenchyma (9). CT, once again, is the modality of choice for detecting parenchymal gas as well as for evaluating its extent and location and evaluating potential complications, including parenchymal necrosis and abscess formation (3,10). The prognosis for emphysematous pancreatitis is grave, and successful treatment requires aggressive management of the infection with systemic antimicrobial therapy, control of septic shock, and early surgical debridement or percutaneous drainage (10).
e87
CONCLUSION Our case was unusual in that there was involvement of both kidneys and pancreas, resulting in emphysematous pyelonephritis and pancreatitis.
REFERENCES 1. Huang JJ, Tseng CC. Emphysematous pyelonephritis. Arch Intern Med 2000;160:797– 805. 2. Muttarak M, Mai WN. Clinics in diagnostic imaging (99). Left emphysematous pyelonephritis. Singapore Med J 2004;45:340 –2. 3. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543– 61. 4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol 1997;157:1569 –73. 5. Huang JJ, Sung JM, Chen KW, Ruaan MK, Shu HF, Chuang YC. Acute bacterial nephritis: a clinico-radiological correlation based on computed tomography. Am J Med 1992;93:289 –98. 6. 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– 8. 7. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735– 47. 8. Roberts JA. Management of pyelonephritis and upper urinary tract infections. Urol Clin North Am 1999;26:753– 63. 9. Ku YM, Kim HK, Cho YS, Chae HS. Medical management of emphysematous pancreatitis. J Gastroenterol Hepatol 2007;22:455– 6. 10. Daly JJ Jr, Alderman DF, Conway WF. General case of the day. Radiographics 1995;15:489 –92.