A case of emphysematous pyelonephritis

Abstract

EMPHYSEMATOUS pyelonephritis is an unusual condition i n which there is gas within the renal parenchyma, or sometimes within the pyelocaliceal collecting system. T h e diagnosis is made radiologically (Bliznak and Ramsey, 1972). Thirty-five cases have been reported in the literature, all of whom had diabetes mellitus or an obstruction to urinary outflow (Costas, 1972).T h e present fatal case illustrates this condition and demonstrates the rapid way in which it may develop. CASE REPORTJ. H., a 42-year-old woman, was admitted as an emergency in a semiconscious state. The relatives gave a history of several months' duration of malaise, urinary frequency, and intermittent burning pains in the feet. Five days prior to admission she had had rigors and nausea; left kidney at the age of 7 years. She had been treated for syphilis when she was 26 years old.The patient looked dehydrated and was drowsy and disorientated, though able to obey simple commands.There was a left paramedian scar. A large tender mass was present in the right renal area. The oral temperature was 37.8" C., sinus tachycardia 140 per minute, and blood-pressure 70/50.Laboratory data on admission included : blood-urea, 185 mg. per IOO ml.; serum sodium, 130 mEq./l.; serum potassium, 5.4 mEq./l.; serum chloride, 85 mEq./l.; blood-sugar, 650 mg. per IOO ml., with a metabolic acidosis; haemoglobin, I 1'2 g. per IOO ml.; white-blood count, 10,000 per mm.3 Blood and urine cultures taken on admission both grew Escherichia coli. The patient was rehydrated and started on kanamycin at a reduced dosage in view of her renal failure (Mawer, Knowles, Lucas, Stirland, and Tooth, 1972;Mawer, Lucas, and McGough, 1972). The diabetes was controlled with soluble insulin.The day after admission the patient remained severely hypotensive and had become anuric with a rapidly rising blood-urea, which was now 380 mg. per IOO ml. She had developed neck stiffness and a positive Kernig's sign. Cerebrospinal fluid obtained by lumbar puncture contained 180 polymorphonuclear cells per mm.3 Plain abdominal radiographs showed multiple gas shadows in the right renal area, and many small opacities in the gluteal region.An abdominal tomogram 3 days after admission (Fig. I) showed evidence of a considerable amount of gas within the right kidney.Peritoneal dialysis was commenced to control the uraemia, and blood was transfused to maintain a central FIG. right renal tomogram demonstrating air within the renal subsrance. FIG. 2.-Interior of the right kidney.she had become increasingly weak. Immediately before venous pressure of + 4 cm. The haemoglobin had admission she had become disorientated and confused. dropped to 9.3 g. per IOO ml., with a platelet count of There was no family history of diabetes mellitus or 18,000 mm.3, and coagulation studies demonstrated renal disease. The patient had had an operation on the intravascular coagulation. controlled. The blood-pressure remained low (about The patient's general condition remained grave although 90 mm. Hg systolic pressure) and there was ev...

Renal Emphysema

“…Three months later she died from a similar infection in remaining right kidney. 35 previous cases of gas formation in the urinary tract as a result of carbohydrate fermentation by aerobic organisms have been described (Costas, 1972;Mosley, 1973). All such cases are associated with obstructive uropathy, diabetes, or both, this last group having a mortality rate of 70%.…”