Emphysematous Pyelonephritis in a Renal Transplant Patient

Emphysematous pyelonephritis (EPN) is a necrotizing bacterial infection of the kidney that is caused by gas-forming organisms. We report a case of a 58-year-old man with a renal transplant who presented to the emergency room with nausea, vomiting and right lower quadrant abdominal pain. At the time of presentation, he was hemodynamically stable, and the abdominal examination was significant for tenderness over the allograft. Urinalysis was positive for large amounts of leukocyte esterase and white blood cells. He received empiric antibiotic coverage with piperacillin/tazobactam. Over the following 24 hours, the patient developed septic shock manifested by hemodynamic instability. A non-contrast CT scan of the abdomen and pelvis elucidated a heterogeneous gas containing collection in the allograft. Emergent transplant nephrectomy was performed. Postoperatively, the patient rapidly recovered and was subsequently discharged home to commence outpatient hemodialysis. A review of the literature suggests that early recognition of the severity of EPN as manifested by hemodynamic instability dictates emergent transplant nephrectomy as the treatment of choice.

Point-of-care ultrasound for the early diagnosis of emphysematous pyelonephritis: A case report and literature review

BACKGROUND Emphysematous pyelonephritis(EPN)is a rare but fatal necrotic infection of the kidney,which usually leads to septic shock.Therefore,early diagnosis and optimized therapy are of paramount importance.In the past two decades,pointof-care ultrasound(POCUS)has been widely used in clinical practice,especially in emergency and critical care settings,and helps to rapidly identify the source of infection in sepsis.We report a rare case in which a“falls”sign on POCUS played a pivotal role in the early diagnosis of EPN.CASE SUMMARY A 57-year-old man presented with fever and lumbago for 3 d prior to admission.He went to the emergency room,and the initial POCUS detected gas bubbles in the hepatorenal space showing a hyperechoic focus with dirty shadowing and comet-tail artifacts.This imaging feature was like a mini waterfall.His blood and urine culture demonstrated Escherichia coli bacteremia,and EPN associated with septic shock was diagnosed.The patient did not respond to broad-spectrum antibiotic treatment and a perirenal abscess developed.He subsequently underwent computed tomography-guided percutaneous catheter drainage,and fully recovered.We also review the literature on the sonographic features of POCUS in EPN.CONCLUSION This case indicates that a“falls”sign on POCUS facilitates the rapid diagnosis of severe EPN at the bedside.

Emphysematous Pyelonephritis with Renal Calculi Treated with Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) today has become the first line treatment for large renal stones. The infective complications of PCNL in patients with emphysematous pyelonephritis EPN would be higher and be responsible for the increased morbidity. We retrospectively reviewed our hospital records of patients with EPN and renal stones undergoing PCNL, and assessed the outcome especially in relation to infection. Materials & Methods: The case records of all patients with EPN and renal stones having undergone PCNL at our centre were retrospectively reviewed and analyzed. The age, gender, presenting symptoms, features of septicemia, preoperative drainage, post-operative complications and outcome were recorded. Results: During the study period, 12 patients (eight females and four males) with a mean age of years who were diagnosed to have EPN, underwent PCNL for extraction of renal calculi. All patients were initially managed conservatively;five patients underwent cystoscopy and Double J stent insertion on the affected side and seven patients underwent PCN insertion. Six weeks later, PCNL was performed (Urine culture was negative) undercover of appropriate antibiotics and general anaesthesia. Nine patients had Class II;two patients had class IIIb and one patient had class IV complications as classified by Clavien-Dindo. All patients recovered well and post-operative x-rays showed clearance of stone in all. Conclusions: Percutaneous nephrolithotomy is a safe, viable option in patients with emphysematous pyelonephritis and renal calculi follows a period of conservative treatment and effective drainage of the pelvicalyceal system by either a ureteric stent or percutaneous nephrostomy. The calculi can be effectively managed with endoscopic measures with renal preservation and a good functional outcome.

What is the prognosis of emphysematous pyelonephritis associated with extended-spectrum beta-lactamases producing microorganisms?

Objective:To describe the microbiological characteristics in emphysematous pyelonephritis(EPN),demonstrate the frequency of extended-spectrum beta-lactamase(ESBL)microorganisms,and determine if these microorganisms are associated with the prognosis of patients with EPN.Methods:We conducted a retrospective study in patients with a diagnosis of EPN in a tertiary care hospital of the northeast region of Mexico during the period from January 2011 to January 2016.Clinical variables were analyzed to determine association with the presence of ESBL-producing microorganisms.Statistical significance was set with p<0.05.Results:A total of 63 patients were included;55(87.3%)of them were females,with a median age of 55(interquartile range:45-65)years.Conservative management was indicated in 38.1%;42.9%were treated with ureteral stent;12.7%with open or percutaneous drainage;15.8%with early nephrectomy;and 9.5%with delayed nephrectomy.Reported mortality was 13(20.6%)cases;23(36.5%)cases required admission to the intensive care unit.The most frequent microorganism isolated was Escherichia coli(n=34,53.9%).ESBL microorganisms were found in 31.7%of the population.No significant association of ESBL was found with admission to the intensive care unit,or with increased mortality.Conclusions:To our knowledge,this is the first study that evaluates ESBL microorganisms as a prognostic factor in EPN.Risk factors associated with a poor prognosis in patients with EPN have been described.The microbiological factors,specifically ESBL-producing bacteria,do not seem to influence in the prognosis of these patients.

Serratia fonticola and its role as a single pathogen causing emphysematous pyelonephritis in a non-diabetic patient:A case report

BACKGROUND Diagnosis of emphysematous pyelonephritis has been described around the world for some decades,frequently associated with Escherichia coli and other anaerobic,gas-forming bacteria and mostly in patients living with diabetes.We present a case report of emphysematous pyelonephritis in a non-diabetic patient caused by Serratia fonticola as well as a brief literature review to draw attention to this rare pathogen as a cause of pyelonephritis.CASE SUMMARY A 38-year-old female presented with fever,severe pain in the right flank and changes in urinary habits.She was admitted,and emphysematous pyelonephritis was confirmed by an abdominal computerized tomography and urine cultures;the latter showed Serratia fonticola as a single pathogen.After 3 d of being treated with piperacillin/tazobactam and percutaneous drainage she became afebrile,and the gas presence reduced.CONCLUSION Emphysematous pyelonephritis infections in non-diabetic patients are rare but can be severe and life-threatening.This case suggests that Serratia fonticola infection can occur in patients undergoing invasive or instrumented procedures.

Emphysematous pyelonephritis:Six case reports and review of literature

BACKGROUND Emphysematous pyelonephritis(EPN)is a severe acute necrotizing infection of the renal parenchyma and surrounding tissues that causes the presence of gas in the renal parenchyma,collecting system,or perinephric tissue and has a poor prognosis.EPN occurs primarily in people with diabetes mellitus(DM),but can occur in those without DM when the associated renoureteral unit is obstructed.CASE SUMMARY We describe our experience with six patients who developed EPN.Five patients had DM,including one with diabetic ketoacidosis,one with multisystem involvements,including eye,lung and brain.Bilateral urolithiasis was present in one case,along with emphysematous cystitis.Unilateral kidney stones were present in one patient.One patient was an older man in poor general health.Five individuals survived and underwent surgical procedures including ureteral stent installation(Double J stent placement),percutaneous nephrostomy and perinephric abscess puncture drainage,while one died because the patient’s family chose to terminate therapy.Klebsiella pneumoniae and Escherichia coli were the microorganisms implicated.CONCLUSION We conclude that EPN is a potentially fatal illness.A positive outcome necessitates early detection.Therapeutic measures should be implemented as soon as a diagnosis is made.

Successful endoscopic surgery for emphysematous pyelonephritis in a non-diabetic patient with autosomal dominant polycystic kidney disease: A case report

BACKGROUND Emphysema pyelonephritis(EPN)is a very dangerous type of urinary tract infection.It is a lethal disease that develops rapidly and causes the patient to deteriorate rapidly,and it can easily lead to systemic infections and even sepsis.The incidence is extremely low,and it is prevalent in patients with diabetes.We here report a case of EPN in a non-diabetic patient with autosomal dominant polycystic kidney disease(ADPKD).We share the diagnosis and treatment procedure for this extremely rare condition to make this disease easier to identify and address early.CASE SUMMARY A 47-year-old woman presented to the emergency department of our hospital with a high fever and left back pain lasting 4 d.She had a history of autosomal dominant polycystic kidney and polycystic liver.She was diagnosed with left type I EPN and her vital signs deteriorated so quickly that she underwent an emergency operation in which a D-J tube was inserted into her left ureter on the second day after admission.Two months later,she underwent a second-stage flexible ureteroscopy and lithotripsy.Despite postoperative sepsis,she finally recovered after active symptomatic support treatment and effective anti-infective treatment.CONCLUSION Although EPN is more likely to occur in diabetic patients,for non-diabetic patients with ADPKD and upper urinary tract obstruction,the disease also causes rapid deterioration.Early and accurate diagnosis and timely removal of the obstruction by invasive means may be able to save the damaged kidney and the patient’s life.

Emphysematous Pyelonephritis in a Black African Woman Managed with Antibiotics Alone

Introduction: Emphysematous pyelonephritis (EPN) is a severe, life-threatening infection of the renal parenchyma. This condition is characterized by the production of intrarenal and perinephric gas. In the world, the EPN is currently limited to case series reported. No cases have been described in black Africa. Aims: Related a first case of EPN diagnosed and treated in the University Hospital Center Sylvanus Olympio of Lomé in Togo. Observation: A 40 years old woman, with antecedent of diabetes presented pyelonephritis emphysematous class 2. She was treated successfully with antibiotic alone without using percutaneous drainage or nephrectomy. Conclusion: As reported in every case series, it was a young diabetic patient with a clinical features of acute pyelonephritis which CT scan had helped lay the EPN class 2 diagnosed. The germ was Klebsiella pneumoniae. She was treated with adapted antibiotic alone.

A novel mortality risk score for emphysematous pyelonephritis:A multicenter study of the Global Research in the Emphysematous Pyelonephritis group

Background:Emphysematous pyelonephritis(EPN)is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality.We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission.Materials and methods:Patients diagnosed with EPN between 2013 and 2020 were retrospectively included.Data from 15 centers(70%)were used to develop the scoring system,and data from 7 centers(30%)were used to validate it.Univariable and mułtivariable logistic regression analyses were performed to identify independent factors related to mortality.Receiver operating characteristic curve analysis was performed to construct the sconng system and calculate the risk of mortality.A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points.The area under the curve was used to quantify the scoring system performance.An 8-point scoring system for the mortality risk was created(range,0-7).Results:In total,570 patients were included(400 in the test group and 170 in the validation group).Independent predictors of mortality in the multivariable logistic regression were included in the scoring system:quick Sepsis-related Organ Failure Assessment score≥2(2 points),anemia,paranephric gas extension,leukocyte count>22,000/pL,thrombocytopenia,and hyperglycemia(1 point each).The mortality rate was<5%for scores≤3,83.3%for scores 6,and 100%for scores 7.The area under the Curve was 0.90(95%confidence interval,0.84-0.95)for test and 0.91(95%confidence interval,0.84-0.97)for the validation group.Condusions:Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.

Emphysematous Pyelonephritis Treated with Vacuum Sealing Drainage

Emphysematous pyelonephritis （EPN） is a rare infectious disease, of which risk factors are poorly controlled diabetes mellitus, immunosuppression, and urinary tract obstruction. In comparison with simple pyelonephritis, EPN is an acute severe necrotizing and gas-forming infection of the renal parenchyma with a mortality rate of up to 25%. Among the reported cases of EPN, there has only been one report of the disease where the ＂invisible kidney＂ was detected in the lung windows on noneontrast abdominal computed tomography （CT）. This rare case was treated with vacuum sealing drainage （VSD, Weigao Holding, China） and recovered quickly.

An alveolate kidney:A case report of emphysema pyelonephritis

Rationale:Emphysematous pyelonephritis is a life-threatening infectious disease that requires early diagnosis and treatment.The disease is often misdiagnosed due to its diversity of clinical manifestations.Patient’s concern:A 62-year-old woman was admitted to the emergency department following a 12-hour history of abdominal pain and dyspnea.Physical examination showed percussion pain on the right costovertebral angle.Besides,she had a history of diabetes mellitus and urinary calculus.Diagnosis:Emphysematous pyelonephritis.Intervention:The patient accepted antishock therapy,tight glucose control,and broad-spectrum anti-infective therapy.After stabilization of the general condition,an ultrasound-guided percutaneous nephrostomy was performed.Outcome:Her conditions became stable over the following days.She presented a favorable clinical course,with normalization of renal function and positive improvements in imaging findings in a month.Lessons:Early diagnosis and rapid medical management are the keys to successful treatment.CT is an important method for the diagnosis of emphysematous pyelonephritis.For patients with severe lesions,percutaneous renal drainage combined with active anti-infection should be given in time.

Step-up approach in emphysematous hepatitis: A case report

BACKGROUND Emphysematous hepatitis(EH)is a rare,rapidly progressive fulminant gasforming infection of the liver parenchyma.It is often fatal and mostly affects diabetes patients.CASE SUMMARY We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support,intravenous antibiotics,and percutaneous drainage,ultimately followed by laparoscopic deroofing.Of 11 documented cases worldwide,only 1 of the patients survived,treated by urgent laparotomy and surgical debridement.CONCLUSION EH is a life-threatening infection.Its high mortality rate makes timely diagnosis essential,in order to navigate treatment accordingly.

气肿性肾盂肾炎的临床诊治及文献回顾

目的探讨气肿性肾盂肾炎患者的临床表现及诊治。方法分析3例气肿性肾盂肾炎患者的临床资料并回顾文献,患者行CT等检查确诊后积极抗感染并行经皮肾穿刺引流。结果 3例患者均为女性,年龄35~64岁之间,2例既往患糖尿病多年且血糖控制较差。均因"发热伴腰痛"入院,病情危重,CT提示肾脏及肾周气性脓肿病变,3例患者均在行经皮肾穿刺引流及抗生素抗感染后治愈出院。结论气肿性肾盂肾炎是一种累及肾实质及肾周的急性坏死性产气性感染,病情危重,CT为其主要诊断方法,多采用抗生素加经皮肾穿刺引流治疗。

糖尿病并气肿性肾盂肾炎误诊为急性肾盂肾炎临床分析

目的探讨气肿性肾盂肾炎(emphysematous pyelonephritis,EPN)的临床诊断与鉴别诊断要点,以防范误诊。方法对1例糖尿病并EPN的临床资料进行回顾性分析并复习相关文献。结果本例以腰腹痛、高热为首发症状就诊,外院拟诊为急性肾盂肾炎,予抗感染治疗无效入我院。经监测血糖、尿酮体及行双肾CT检查诊断为糖尿病酮症酸中毒、EPN,予抗感染、控制血糖、纠正糖尿病酮症酸中毒及对症支持治疗,同时在超声引导下行经皮肾穿刺置管引流,1 d后症状即缓解,8 d后CT检查示肾脏积气积液消失,11 d后血尿常规及肾功能恢复正常。结论 EPN为急危重症,临床较为少见,易误诊。临床应加强对EPN CT影像特点的认识,以期早诊断并治疗。

气肿性肾盂肾炎10例影像学诊断

目的 :分析气肿性肾盂肾炎病人的影像学表现 ,评价各种检查方法的优缺点 ,选择最敏感的检查手段。方法 :收集经手术病理证实的 10例气肿性肾盂肾炎 ,分析其腹部平片 (KUB)、静脉尿路造影 (IVP)、B超及CT表现 ,并进行比较。结果 :KUB及IVP诊断率为 4 0 % (4 10 ) ,B超 2 0 % (2 10 ) ,CT 10 0 % (10 10 )。CT特点表现为 :肾区大量气体与残存低密度肾组织并存。结论 :CT是诊断气肿性肾盂肾炎最快捷、准确的检查手段。

糖尿病并发气肿性肾盂肾炎临床分析并文献复习

目的探讨气肿性肾盂肾炎(emphysematous pyelonephritis,EPN)的临床表现、病因学、诊断及治疗方法。方法对本院收治的一例临床确诊为气肿性肾盂肾炎患者的资料进行总结分析,并通过文献复习进一步总结。结果气肿性肾盂肾炎好发于成人女性糖尿病患者,病情急发且危重、死亡率高,CT为最佳影像诊断方法,治疗方法既往常选择肾切除,近年更多选择抗感染加外引流或内引流的方法。结论气肿性肾盂肾炎为肾实质和肾周的产气性感染,病情凶险,选择CT检查为宜,并及时抗感染并外引流/内引流,必要时选择肾切除。

光滑念珠菌致气性肾盂肾炎1例

患者女,69岁,因“右侧腰背部痛1个月”就诊;既往2型糖尿病史半年,血糖控制不佳。查体:体温39.5℃,左侧腰背部压痛,右肾区扣击痛阳性。实验室检查:白细胞35.91×10^9/L,中性粒细胞96.2%,全血C反应蛋白150 mg/L;尿白细胞136.1/μl,尿红细胞54.9/μl,尿蛋白++,尿肌酐221μmol/L,尿素氮32.1 mmol/L。CT平扫:右肾呈肿块样增大,边界欠清,密度较均匀;右肾实质内及肾周散在气体密度影;右肾周间隙模糊,肾周筋膜增厚(图1)。CT诊断:考虑为气性肾盂肾炎。行超声引导下右肾穿刺引流术,见大量白色絮状物流出;光镜下见光滑念珠菌孢子及菌丝;尿液培养与之相符。通过药物敏感试验选择5-氟胞嘧啶、两性霉素B静脉滴注,同时进行血糖管理。1周后复查CT,见右肾体积缩小,右肾及肾周积气减少,右侧肾周渗出改变减轻。

气肿性肾盂肾炎致突发呼吸心跳骤停1例及文献综述

目的报告气肿性肾盂肾炎致突发呼吸心跳骤停1例及进行文献回顾总结。方法报告1例气肿性肾盂肾炎导致突发呼吸心跳骤停患者的临床资料并总结既往文献报道。结果本例患者由于延误就诊,病情危重,拟急诊行患肾切除术,在进入手术室后发生呼吸心跳骤停,抢救无效而死亡。结论气肿性肾盂肾炎广泛气肿破坏肾实质需行肾切除术,延误治疗可导致突发呼吸心跳骤停,需密切监护及预防。

气肿性肾盂肾炎合并感染性休克1例报告及相关分析

目的探讨气肿性肾盂肾炎(Emphysematous pyelonephritis,EPN)的诊断与鉴别诊断要点,减低误诊可能。方法对1例EPN并感染性休克患者进行分析及相关文献学习。结果本例以休克急诊入院,外院诊断为重症感染,为求进一步治疗转入本院,经检测血糖、血常规、超声双肾检查及CT双肾检查确诊为感染性休克、EPN、糖尿病,予以抗感炎、控制血糖及对症支持治疗,同时行超声引导下肾穿刺引流术,患者尿量逐渐增多,生命体征基本稳定。结论EPN临床少见,进展迅速,病死率高,易误诊。加强对EPN图像的认识,达到影像学检查及早提示的效果。

气肿性肾盂肾炎的临床诊疗

目的气肿性肾盂肾炎(emphysematous pyelonephritis,EPN)作为罕见的泌尿外科急症,治疗方式至今仍存在争议,本文旨在探讨治疗EPN时穿刺引流以及急诊肾切除的优缺点,为EPN的诊疗提供临床依据。方法回顾性分析11例EPN临床资料,并复习最新相关文献,综合分析该疾病的的治疗方式及预后。结果11例EPN中诊断为Ⅰ型4例,Ⅱ型7例,就诊时发生感染性休克2例且均为Ⅰ型。1例I型EPN患者接受经皮穿刺引流术后感染控制不良,于次日行急诊肾切除术;其余3例I型EPN均直接行急诊肾切除术;所有Ⅰ型EPN患者术后均转入ICU治疗,死亡1例,生存率为75%。7例II型EPN均急诊行经皮穿刺引流术,留置2根或以上引流管3例,术后2例转入ICU,择期切除无功能肾2例,保肾率为72%,所有患者均痊愈。结论急诊肾切除术创伤大,但可及时清除感染的坏死组织,适用于Ⅰ型EPN,可提高患者生存率;而经皮穿刺引流术创伤小、操作简单,适用于Ⅱ型EPN,可以最大程度的挽救患肾功能。