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Percutaneous Management of Localized Emphysematous Pyelonephritis
Case Report
Percutaneous Management of Localized Emphysematous Pyelonephritisl Ronald J. Zagoria, MD Raymond 6. Dyer, MD Uoyd H. Harrison, MD Patricia L. Adams, MD
.
Index terms: Kidney, abscess, 81.2111 Kidney, infection, 81.212,81.218 Kidney, interventional procedure, 81.1299 Nephritis, 81.212,81.218
JVIR 1991; 2156-158
The authors report a case of emphysematous pyelonephritis that was successfully treated with radiologically guided percutaneous drainage. This case illustrates that in certain patients with focal abnormalities,functioning renal tissue can be salvaged and emphysematous pyelonephritis can be eradicated with a combination of antibiotics and radiologically guided percutaneous drainage.
EMPHYSEMATOUS
pyelonephritis is a severe, necrotizing renal infection characterized by gas within the renal parenchyma that is visible radiographically. Patients with this infection usually have diabetes. Nephrectomy has been advocated as the best treatment for these patients (1) because of the fulminant course of the disease and evidence that renal function has been irreversibly lost in the affected kidney. We report a case of localized emphysematous pyelonephritis that was successfully treated with percutaneous drainage, ureteral stent placement, and antibiotic therapy with resultant preservation of function in the affected kidney.
in the right kidney and perinephric space.
From the Departments of Radiology (R.J.Z., R.B.D.), Urology (L.H.H.), and Nephrology (P.L-4.); Bowman Gray School of Medicine, 300 Hawthorne Rd9WinstonSalem, NC 27103. Received August 15, 1990; revision requested November 5; revision received ~~~~~b~~ 28; accepted N ~ vember 30. Address reprint requests to R.J.Z. @ SCVIR, 1991
156
CASE REPORT A 75-year-old woman with diabetes was transferred to our institution when she developed hypotension with acute renal failure after a 6-day illness characterized by nausea, vomiting, and decreased mental status. On admission to our hospital, she was receiving intravenously administered ceftizoxime and was afebrile. Her serum creatinine level was 6.0 mg/dL (530.4 pmol/L), and her blood urea nitrogen level was 144 mg/ dL (51.4 mmol/L). Except for a 20-year history of diabetes mellitus and one prior episode of confusion related to acute renal failure, her history was noncontributory. Urinalysis revealed a large number of white blood cells with scattered bacteria. A renal ultrasonogram obtained at this time demonstrated a focal lesion in the right kidney suggestive of an abscess. Her initial antibiotic
therapy was augmented with intravenously administered vancomycin, but there was no clinical improvement after 2 days of this regimen. Computed tomographic (CT) scans of the abdomen were then obtained, and they demonstrated gas within the right renal parenchyma with extension into the perinephric space, right hydronephrosis, and calcified debris within the right renal collecting system (Fig 1). A retrograde pyelogram obtained the same day demonstrated a partially obstructing filling defect of decreased opacity in the middle of the right ureter and multiple filling defects of decreased opacity within the ureter and collecting system. All of these filling defects were thought to represent sloughed renal papilla. An 8-F ureteral catheter was placed cytoscopically. With fluoroscopic guid-
Zagoria et a1
157
Volume 2 Number 1
were 2.3 mg/dL (203 ~ m o l / L )and 28 mg/dL (10.0 mmol/L), respectively.
DISCUSSION
Figure 2. Radiograph taken during simultaneous injection of contrast material into the ureteral and drainage catheters demonstrating the intraparenchymal location of the renal infection and several sloughed papillae in the renal pelvis (arrows).
Figure 4. CT scan demonstrating complete resolution of emphysematous pyelonephritis and shrinkage of the fungal abscess (arrow).
ance, a 10-F Cope loop drainage catheter (Cook, Bloomington, Ind) was then placed into the gas-containing cavity in the kidney. Purulent material and gas were drained via this catheter, and injection of contrast material through the catheter demonstrated no collecting system communication. Culture of the drained material grew Escherichia coli.
Figure 3. CT scan of the right kidney demonstrating a fungal abscess (arrow) and calcified sloughed papillae in the renal pelvis. Caliceal gas was introduced via a ureteral catheter.
The patient's clinical status improved rapidly, but she developed a persistent low-grade fever. The externalized ureteral stent was replaced with an internal ureteral stent 10 days after initial placement, after acquisition of a retrograde pyelogram that demonstrated an unobstructed ureter, persistent filling defects in the collecting system, and papillary necrosis (Fig 2). Two days later, a CT scan demonstrated persistence of a discrete area of low attenuation in the anterior portion of the right kidney, while the main abscess cavity had nearly resolved (Fig 3). Candida albicans was aspirated from the anterior portion of the right kidney with a needle placed under CT guidance. After acquisition of a renogram demonstrating that the right kidney accounted for 58% of the patient's functioning renal mass, the patient was given intravenous amphotericin B. The patient's fever subsided, and she remained afebrile until discharge. The abscess drainage catheter was removed 23 days after its insertion. Thirty-two days after admission, several sloughed papillae were removed percutaneously from the right renal collecting system via a new nephrostomy tract. Prior to discharge, the patient was in good condition, and a CT scan demonstrated complete resolution of emphysematous pyelonephritis and partial resolution of the fungal abscess (Fig 4). At discharge, the patient's serum creatinine and blood urea nitrogen levels
Emphysematous pyelonephritis is a rare infection seen mostly in diabetic patients and occasionally in other patients who usually have compromised renal vasculature (2). While diagnosis is often possible with plain radiographs, CT is the most accurate modality for localizing gas collections in the urinary tract (3). Management of this infection has been controversial. The mortality rate in patients treated with antibiotics without nephrectomy has been greater than 60% (3), and in those who survive, function in the affected kidney has been greatly reduced or is absent (2). Although immediate nephrectomy is usually advocated for emphysematous pyelonephritis, the procedure has been associated with a 42% mortality rate, usually due to sepsis (1). In addition, nephrectomy may lead to renal insufficiency since underlying renal vascular disease is usually present in these patients. In two reported cases, antibiotic therapy with radiologically guided placement of percutaneous drainage catheters resulted in resolution of emphysematous pyelonephritis with preservation of renal function (4,5). As in this case, obstructive uropathy should be adequately drained with percutaneous catheter drainage of the parenchymal infection. This will enhance blood flow and antibiotic delivery to the affected kidney. In the present case, as well as in previous reports of successful nonsurgical management of emphysematous pyelon e ~ h r i t i (4.5). s CT demonstrated localized emphysematous areas within the kidney. We believe that this localized form of emphysematous pyelonephritis should be distinguished from diffuse emphysematous pyelonephritis for treatment purposes. When infection is localized, it is more likely that renal parenchyma is salvageable, and percutaneous catheter drainage can be attempted in these cases. Diffuse emphysematous pyelonephritis is probably best managed with nephrectomy because of the likelihood that the loss of
158
Journal of Vascular and Interventional Radiology
February 1991
renal function is complete. Nonoperative treatment was chosen for our patient because of her poor medical status, the localized nature of the emphysematous changes, and the desire to preserve a viable kidney. This case illustrates that in certain patients, functioning renal tissue can be salvaged, and emphysematous pyelonephritis can be treated successfully with antibiotics and radiologically guided percutaneous drainage.
References 1. Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5year experience with 13 patients. J Urol 1985; 1341086-1088. 2. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis: a new case and review of previous observations. Am J Med 1968; 44134-139. 3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney: emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 1987; 83:149-154.
4. Hudson MA, Weyman PJ, van der Vliet AH, Catalona WJ. Emphysematous pyelonephritis: successful management by percutaneous drainage. J Urol1986; 136:884-886. 5. Hall JRW, Choa RG, Wells IP. Percutaneous drainage in emphysematous pyelonephritis: an alternative to major surgery. Clin Radio1 1988; 39:622-624.
Percutaneous Management of Localized Emphysematous Pyelonephritisl Ronald J. Zagoria, MD Raymond 6. Dyer, MD Uoyd H. Harrison, MD Patricia L. Adams, MD
.
Index terms: Kidney, abscess, 81.2111 Kidney, infection, 81.212,81.218 Kidney, interventional procedure, 81.1299 Nephritis, 81.212,81.218
JVIR 1991; 2156-158
The authors report a case of emphysematous pyelonephritis that was successfully treated with radiologically guided percutaneous drainage. This case illustrates that in certain patients with focal abnormalities,functioning renal tissue can be salvaged and emphysematous pyelonephritis can be eradicated with a combination of antibiotics and radiologically guided percutaneous drainage.
EMPHYSEMATOUS
pyelonephritis is a severe, necrotizing renal infection characterized by gas within the renal parenchyma that is visible radiographically. Patients with this infection usually have diabetes. Nephrectomy has been advocated as the best treatment for these patients (1) because of the fulminant course of the disease and evidence that renal function has been irreversibly lost in the affected kidney. We report a case of localized emphysematous pyelonephritis that was successfully treated with percutaneous drainage, ureteral stent placement, and antibiotic therapy with resultant preservation of function in the affected kidney.
in the right kidney and perinephric space.
From the Departments of Radiology (R.J.Z., R.B.D.), Urology (L.H.H.), and Nephrology (P.L-4.); Bowman Gray School of Medicine, 300 Hawthorne Rd9WinstonSalem, NC 27103. Received August 15, 1990; revision requested November 5; revision received ~~~~~b~~ 28; accepted N ~ vember 30. Address reprint requests to R.J.Z. @ SCVIR, 1991
156
CASE REPORT A 75-year-old woman with diabetes was transferred to our institution when she developed hypotension with acute renal failure after a 6-day illness characterized by nausea, vomiting, and decreased mental status. On admission to our hospital, she was receiving intravenously administered ceftizoxime and was afebrile. Her serum creatinine level was 6.0 mg/dL (530.4 pmol/L), and her blood urea nitrogen level was 144 mg/ dL (51.4 mmol/L). Except for a 20-year history of diabetes mellitus and one prior episode of confusion related to acute renal failure, her history was noncontributory. Urinalysis revealed a large number of white blood cells with scattered bacteria. A renal ultrasonogram obtained at this time demonstrated a focal lesion in the right kidney suggestive of an abscess. Her initial antibiotic
therapy was augmented with intravenously administered vancomycin, but there was no clinical improvement after 2 days of this regimen. Computed tomographic (CT) scans of the abdomen were then obtained, and they demonstrated gas within the right renal parenchyma with extension into the perinephric space, right hydronephrosis, and calcified debris within the right renal collecting system (Fig 1). A retrograde pyelogram obtained the same day demonstrated a partially obstructing filling defect of decreased opacity in the middle of the right ureter and multiple filling defects of decreased opacity within the ureter and collecting system. All of these filling defects were thought to represent sloughed renal papilla. An 8-F ureteral catheter was placed cytoscopically. With fluoroscopic guid-
Zagoria et a1
157
Volume 2 Number 1
were 2.3 mg/dL (203 ~ m o l / L )and 28 mg/dL (10.0 mmol/L), respectively.
DISCUSSION
Figure 2. Radiograph taken during simultaneous injection of contrast material into the ureteral and drainage catheters demonstrating the intraparenchymal location of the renal infection and several sloughed papillae in the renal pelvis (arrows).
Figure 4. CT scan demonstrating complete resolution of emphysematous pyelonephritis and shrinkage of the fungal abscess (arrow).
ance, a 10-F Cope loop drainage catheter (Cook, Bloomington, Ind) was then placed into the gas-containing cavity in the kidney. Purulent material and gas were drained via this catheter, and injection of contrast material through the catheter demonstrated no collecting system communication. Culture of the drained material grew Escherichia coli.
Figure 3. CT scan of the right kidney demonstrating a fungal abscess (arrow) and calcified sloughed papillae in the renal pelvis. Caliceal gas was introduced via a ureteral catheter.
The patient's clinical status improved rapidly, but she developed a persistent low-grade fever. The externalized ureteral stent was replaced with an internal ureteral stent 10 days after initial placement, after acquisition of a retrograde pyelogram that demonstrated an unobstructed ureter, persistent filling defects in the collecting system, and papillary necrosis (Fig 2). Two days later, a CT scan demonstrated persistence of a discrete area of low attenuation in the anterior portion of the right kidney, while the main abscess cavity had nearly resolved (Fig 3). Candida albicans was aspirated from the anterior portion of the right kidney with a needle placed under CT guidance. After acquisition of a renogram demonstrating that the right kidney accounted for 58% of the patient's functioning renal mass, the patient was given intravenous amphotericin B. The patient's fever subsided, and she remained afebrile until discharge. The abscess drainage catheter was removed 23 days after its insertion. Thirty-two days after admission, several sloughed papillae were removed percutaneously from the right renal collecting system via a new nephrostomy tract. Prior to discharge, the patient was in good condition, and a CT scan demonstrated complete resolution of emphysematous pyelonephritis and partial resolution of the fungal abscess (Fig 4). At discharge, the patient's serum creatinine and blood urea nitrogen levels
Emphysematous pyelonephritis is a rare infection seen mostly in diabetic patients and occasionally in other patients who usually have compromised renal vasculature (2). While diagnosis is often possible with plain radiographs, CT is the most accurate modality for localizing gas collections in the urinary tract (3). Management of this infection has been controversial. The mortality rate in patients treated with antibiotics without nephrectomy has been greater than 60% (3), and in those who survive, function in the affected kidney has been greatly reduced or is absent (2). Although immediate nephrectomy is usually advocated for emphysematous pyelonephritis, the procedure has been associated with a 42% mortality rate, usually due to sepsis (1). In addition, nephrectomy may lead to renal insufficiency since underlying renal vascular disease is usually present in these patients. In two reported cases, antibiotic therapy with radiologically guided placement of percutaneous drainage catheters resulted in resolution of emphysematous pyelonephritis with preservation of renal function (4,5). As in this case, obstructive uropathy should be adequately drained with percutaneous catheter drainage of the parenchymal infection. This will enhance blood flow and antibiotic delivery to the affected kidney. In the present case, as well as in previous reports of successful nonsurgical management of emphysematous pyelon e ~ h r i t i (4.5). s CT demonstrated localized emphysematous areas within the kidney. We believe that this localized form of emphysematous pyelonephritis should be distinguished from diffuse emphysematous pyelonephritis for treatment purposes. When infection is localized, it is more likely that renal parenchyma is salvageable, and percutaneous catheter drainage can be attempted in these cases. Diffuse emphysematous pyelonephritis is probably best managed with nephrectomy because of the likelihood that the loss of
158
Journal of Vascular and Interventional Radiology
February 1991
renal function is complete. Nonoperative treatment was chosen for our patient because of her poor medical status, the localized nature of the emphysematous changes, and the desire to preserve a viable kidney. This case illustrates that in certain patients, functioning renal tissue can be salvaged, and emphysematous pyelonephritis can be treated successfully with antibiotics and radiologically guided percutaneous drainage.
References 1. Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5year experience with 13 patients. J Urol 1985; 1341086-1088. 2. Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephritis: a new case and review of previous observations. Am J Med 1968; 44134-139. 3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney: emphysematous pyelonephritis and emphysematous pyelitis. Am J Med 1987; 83:149-154.
4. Hudson MA, Weyman PJ, van der Vliet AH, Catalona WJ. Emphysematous pyelonephritis: successful management by percutaneous drainage. J Urol1986; 136:884-886. 5. Hall JRW, Choa RG, Wells IP. Percutaneous drainage in emphysematous pyelonephritis: an alternative to major surgery. Clin Radio1 1988; 39:622-624.