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Successful medical management of emphysematous pyelonephritis
Letters to the Editor 3. Karp CL, Neva FA. Tropical infectious diseases in HIV-infected patients. Clin Infect Dis. 1999;28:947–965. 4. Pearson RD, De Queiroz-Sousa A. Clinical spectrum of leishmaniasis. Clin Infect Dis. 1996;22:1–13. 5. Medrano FJ, Jime´ nez-Mejı´as E, Calderon C, et al. An easy and quick method for the diagnosis of visceral Leishmaniasis in HIV1-infected individuals [letter]. AIDS. 1993; 7:1399. 6. Molina R, Can˜ avate C, Cercenado E, et al. Indirect xenodiagnosis of visceral leishmaniasis in 10 HIV-infected patients using colonized. Plebotomus pernicious. AIDS. 1994;8:277–279. 7. Alvar J, Can˜ avate C, Gutie´ rrez-Solar B, et al. Leishmania and human immunodeficiency virus coinfection: the first 10 years. Clin Microbiol Rev. 1997;10:298 –319. 8. Lainson R, Shaw JJ. Classification and geographic distribution. In: Peters W, KillickKendrick R, eds. The Leishmaniases in Biology and Medicine. Vol 1. London: Academic Press; 1987:1–120. 9. Pearson RD, De Queiroz Sousa A. Leishmania species: visceral, cutaneous, and mucosal leishmaniasis. In: Mandell GL, Benett JE, Dolin R, eds. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 4th ed. New York: Churchill Livingston; 1994:2428 –2442. 10. Piarroux R, Gambarelli F, Dumon H, et al. Comparison of PCR with direct examination of bone marrow aspiration, myeloculture and serology for diagnosis of visceral leishmaniasis in immunocompromised patients. J Clin Microbiol. 1994;32:746–749.
SUCCESSFUL MEDICAL MANAGEMENT OF EMPHYSEMATOUS PYELONEPHRITIS To the Editor: Emphysematous pyelonephritis is a rare, life-threatening infection of the upper urinary tract that is characterized by bacterial acid fermentation of glucose leading to gas production. Surgery is the mainstay treatment. We report a case of emphysematous pyelonephritis that was managed successfully with medical therapy. A 40-year-old woman with no prior medical history presented with epigastric pain, vomiting, and polyuria that progressed over several days. On physical examination, she was ill looking, afebrile, and hemodynami262
August 15, 2002
Figure. Computed tomographic scan showing an enlarged left kidney with emphysematous changes.
cally stable, with moderate epigastric tenderness. Her white blood cell count was 25 ⫻ 109/L, blood glucose level was 644 mg/dL, arterial pH was 7.39, and bicarbonate level was 17 mmol/L, and ketones were detected in the serum. An abdominal computerized tomography (CT) scan showed a markedly enlarged left kidney with multiple low-density areas with air and a small subcapsular fluid collection (Figure). The picture was consistent with emphysematous pyelonephritis and newonset diabetes with ketosis. Intravenous piperacillin/tazobactam was started on the same day, together with intravenous fluids and insulin therapy. Blood and urine cultures grew Klebsiella pneumoniae susceptible to the antibiotic regimen that was continued for 2 weeks. The patient responded well and was discharged. Four months later, she was in good health, with normal kidney function. Follow-up magnetic resonance imaging of the abdomen showed a small left kidney with no residual emphysematous changes. Emphysematous pyelonephritis should be suspected in diabetic patients presenting with pyelonephritis and who fail to respond to appropriate treatment. Ninety percent of patients with emphysematous pyelonephritis have diabetes (1), and in a review of 20 cases, 75% were women and 60% involved the left kidney (2).
THE AMERICAN JOURNAL OF MEDICINE威
Volume 113
Escherichia coli is the most common pathogen, although K. pneumoniae can be implicated (2,3). A screening imaging study should be performed using an abdominal radiograph, sonography, intravenous urography, or, most preferably, a CT scan (4). Magnetic resonance imaging can also be used for diagnosis and follow-up (5). There are two radiological types of emphysematous pyelonephritis: type 1, which is characterized by parenchymal destruction, the absence of fluid collection, and the presence of mottled gas, and type 2, which is marked by fluid collections and bubbly gas (as described in our patient). In a retrospective review of 38 cases, mortality in those with type 1 disease was higher than in those with type 2 disease (69% vs. 18%) (6). Emphysematous pyelonephritis is fatal if not recognized early. Surgery is almost always mandatory, involving nephrectomy or nephrostomy. In the case series involving the 20 patients, 1 died within 24 hours of hospitalization, and the remaining patients underwent nephrectomy, with an 80% survival rate (2). Successful medical management alone has been reported infrequently (7–9). Because emphysematous pyelonephritis is associated with substantial mortality, it should be suspected in diabetic patients with pyelonephritis. However, although
Letters to the Editor
aggressive medical management may be attempted, surgery should not be delayed in patients who fail to respond to conservative treatment. Mamoun Najjar, MD Hossam E. Gouda, MD Long Island Jewish Medical Center The Albert Einstein College of Medicine New Hyde Park, New York Pedro Rodriguez, MD Shadab Ahmed, MD East Meadow Campus of the State University of New York at Stony Brook East Meadow, New York
1. Pangoux C, Cazaala JB, Mejean A, et al. Emphysematous pyelonephritis in diabetics: review of reported cases [in French]. Rev Med Interne. 1997;18:888 –892. 2. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49:343–346. 3. Heritier P, Perraud Y, Selles M, et al. Emphysematous pyelonephritis [in French]. J Urol (Paris). 1990;96:60 –61. 4. Kuo YT, Chen MT, Liu GC, et al. Emphysematous pyelonephritis: imaging diagnosis and follow up. Kaohsiung J Med Sci. 1999; 15:159 –170. 5. Goldman SM, Fishman EK. Upper urinary tract infection: the current role of CT, ultra-
August 15, 2002
6.
7.
8.
9.
sound, and MRI. Semin Ultrasound CT MR. 1991;12:335–360. 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. Labussiere AS, Gazaigne J, Walker P, Laplace M. Emphysematous pyelonephritis: a case medically treated [in French]. J Urol (Paris). 1996;102:127–129. Nagappan R, Kletchko S. Bilateral emphysematous pyelonephritis resolving to medical therapy. J Intern Med. 1992;232:77–80. Punnose J, Yahya TM, Premchandran JS, Ahmed HF. Emphysematous pyelonephritis responding to medical therapy. Int J Clin Pract. 1997;51:468 –470.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 113 263
SUCCESSFUL MEDICAL MANAGEMENT OF EMPHYSEMATOUS PYELONEPHRITIS To the Editor: Emphysematous pyelonephritis is a rare, life-threatening infection of the upper urinary tract that is characterized by bacterial acid fermentation of glucose leading to gas production. Surgery is the mainstay treatment. We report a case of emphysematous pyelonephritis that was managed successfully with medical therapy. A 40-year-old woman with no prior medical history presented with epigastric pain, vomiting, and polyuria that progressed over several days. On physical examination, she was ill looking, afebrile, and hemodynami262
August 15, 2002
Figure. Computed tomographic scan showing an enlarged left kidney with emphysematous changes.
cally stable, with moderate epigastric tenderness. Her white blood cell count was 25 ⫻ 109/L, blood glucose level was 644 mg/dL, arterial pH was 7.39, and bicarbonate level was 17 mmol/L, and ketones were detected in the serum. An abdominal computerized tomography (CT) scan showed a markedly enlarged left kidney with multiple low-density areas with air and a small subcapsular fluid collection (Figure). The picture was consistent with emphysematous pyelonephritis and newonset diabetes with ketosis. Intravenous piperacillin/tazobactam was started on the same day, together with intravenous fluids and insulin therapy. Blood and urine cultures grew Klebsiella pneumoniae susceptible to the antibiotic regimen that was continued for 2 weeks. The patient responded well and was discharged. Four months later, she was in good health, with normal kidney function. Follow-up magnetic resonance imaging of the abdomen showed a small left kidney with no residual emphysematous changes. Emphysematous pyelonephritis should be suspected in diabetic patients presenting with pyelonephritis and who fail to respond to appropriate treatment. Ninety percent of patients with emphysematous pyelonephritis have diabetes (1), and in a review of 20 cases, 75% were women and 60% involved the left kidney (2).
THE AMERICAN JOURNAL OF MEDICINE威
Volume 113
Escherichia coli is the most common pathogen, although K. pneumoniae can be implicated (2,3). A screening imaging study should be performed using an abdominal radiograph, sonography, intravenous urography, or, most preferably, a CT scan (4). Magnetic resonance imaging can also be used for diagnosis and follow-up (5). There are two radiological types of emphysematous pyelonephritis: type 1, which is characterized by parenchymal destruction, the absence of fluid collection, and the presence of mottled gas, and type 2, which is marked by fluid collections and bubbly gas (as described in our patient). In a retrospective review of 38 cases, mortality in those with type 1 disease was higher than in those with type 2 disease (69% vs. 18%) (6). Emphysematous pyelonephritis is fatal if not recognized early. Surgery is almost always mandatory, involving nephrectomy or nephrostomy. In the case series involving the 20 patients, 1 died within 24 hours of hospitalization, and the remaining patients underwent nephrectomy, with an 80% survival rate (2). Successful medical management alone has been reported infrequently (7–9). Because emphysematous pyelonephritis is associated with substantial mortality, it should be suspected in diabetic patients with pyelonephritis. However, although
Letters to the Editor
aggressive medical management may be attempted, surgery should not be delayed in patients who fail to respond to conservative treatment. Mamoun Najjar, MD Hossam E. Gouda, MD Long Island Jewish Medical Center The Albert Einstein College of Medicine New Hyde Park, New York Pedro Rodriguez, MD Shadab Ahmed, MD East Meadow Campus of the State University of New York at Stony Brook East Meadow, New York
1. Pangoux C, Cazaala JB, Mejean A, et al. Emphysematous pyelonephritis in diabetics: review of reported cases [in French]. Rev Med Interne. 1997;18:888 –892. 2. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49:343–346. 3. Heritier P, Perraud Y, Selles M, et al. Emphysematous pyelonephritis [in French]. J Urol (Paris). 1990;96:60 –61. 4. Kuo YT, Chen MT, Liu GC, et al. Emphysematous pyelonephritis: imaging diagnosis and follow up. Kaohsiung J Med Sci. 1999; 15:159 –170. 5. Goldman SM, Fishman EK. Upper urinary tract infection: the current role of CT, ultra-
August 15, 2002
6.
7.
8.
9.
sound, and MRI. Semin Ultrasound CT MR. 1991;12:335–360. 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. Labussiere AS, Gazaigne J, Walker P, Laplace M. Emphysematous pyelonephritis: a case medically treated [in French]. J Urol (Paris). 1996;102:127–129. Nagappan R, Kletchko S. Bilateral emphysematous pyelonephritis resolving to medical therapy. J Intern Med. 1992;232:77–80. Punnose J, Yahya TM, Premchandran JS, Ahmed HF. Emphysematous pyelonephritis responding to medical therapy. Int J Clin Pract. 1997;51:468 –470.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 113 263