Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review

Junqiong Peng; Yuxi Ge; Gen Yan

doi:10.4103/RID.RID_9_21

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 2 | Page : 68-74

Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review

Junqiong Peng¹, Yuxi Ge², Gen Yan³
¹ Department of Nephrology, Affiliated Hospital of Jiangnan University, Wuxi, China
² Department of Radiology, Affiliated Hospital of Jiangnan University, Wuxi, China
³ Department of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China

Date of Submission	01-Oct-2021
Date of Acceptance	18-Jun-2022
Date of Web Publication	8-Nov-2022

Correspondence Address:
Gen Yan
Department of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian
China

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/RID.RID_9_21

Abstract

Emphysematous pyelonephritis (EPN) is a rare but serious infectious disease caused by anaerobic bacteria that is characterized by necrotizing renal parenchymal infection and has a high mortality rate. The initial management of EPN includes resuscitation, antibiotics, management of any diabetes, and minimally invasive procedures, such as percutaneous drainage. Surgery is required in the most severe cases. Here, we describe a male patient with type 2 diabetes who presented with fever and abdominal pain and was diagnosed with EPN based on laboratory results and a computed tomography (CT) scan showing distension of the left kidney, several small air bubbles in the perirenal space, and thickening of the perinephric fascia. A subcutaneous insulin infusion and meropenem were administered. Repeat CT imaging 13 days later showed gas and necrotic tissue in the renal parenchyma. Therefore, CT-guided renal puncture was performed, and Escherichia coli was cultured from the drained pus. Antibiotic treatment was continued for 20 days after admission when the patient's kidney function and clinical symptoms had significantly improved. Sixty days after diagnosis, left nephrectomy was performed. The perinephric abscess was under high tension, and the left kidney was very soft. Histopathological examination revealed severe inflammation and necrosis of the renal pelvis, with fibrosis. The patient recovered well after surgery and remained alive 5 months later. EPN is a very rare disease with a high mortality rate and is more likely to occur in patients with diabetes. Early diagnosis and treatment of the infection are extremely important. For patients in whom gas and/or necrosis continue to accumulate after conservative treatment, we recommend nephrectomy.

Keywords: Acute kidney injury, antibiotic, diabetes mellitus, emphysematous pyelonephritis, nephrectomy

How to cite this article:
Peng J, Ge Y, Yan G. Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review. Radiol Infect Dis 2022;9:68-74

How to cite this URL:
Peng J, Ge Y, Yan G. Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review. Radiol Infect Dis [serial online] 2022 [cited 2023 Jun 5];9:68-74. Available from: http://www.ridiseases.org/text.asp?2022/9/2/68/360507

Introduction

Emphysematous pyelonephritis (EPN) is an acute, severe, and necrotizing disease caused by gas-producing bacteria, such as Escherichia coli and Klebsiella pneumoniae, which infect the kidney parenchyma and surrounding tissues. EPN is more common in patients with diabetes and in women.^[1] The most common clinical manifestations are fever, abdominal pain, and pyuria; most patients present with several symptoms. If a patient develops sepsis, the risk of mortality increases dramatically.^[2] At present, there is no consensus regarding the diagnosis and treatment of EPN, but computed tomography (CT) is the current gold standard diagnostic test.^[3] EPN treatment mainly comprises antibiotics, hypoglycemic drugs, percutaneous catheterization and drainage, and surgery. However, there is controversy regarding the indications for and optimal timing of surgical interventions.

Case Presentation

A 55-year-old male was admitted to the hospital because of left-sided lumbago and gross hematuria of 2 weeks' duration, accompanied by obvious fatigue, frequent micturition, and fever. He also had a history of diabetes. His vital signs on admission were as follows: temperature, 37.7°C; pulse rate, 90 beats/min; respiratory rate, 15 breaths/min; and blood pressure, 112/67 mmHg. Physical examination revealed dull abdominal pain but no rebound tenderness or percussion tenderness in the left renal area.

Laboratory examination revealed the following: white blood cell count, 30 × 10⁹/L; neutrophils, 93%; fasting glucose concentration, 23.48 mmol/L; creatinine concentration, 247.7 μmol/L; glycosylated hemoglobin level, 10.4%; C-reactive protein concentration, 448.39 mg/L; and procalcitonin concentration >100.0 ng/ml. Urinalysis revealed the following: glucose, 4+; white blood cell count, 1460.9/μl; and red blood cell count, 3487.7/μl. Blood and urine cultures were negative. Abdominal CT demonstrated that the left kidney was distended, with low renal parenchymal density. In addition, several small air bubbles that were consistent with anaerobic infection were present in the upper part of the perirenal space, with a minor effusion in the perirenal space and thickening of the perirenal fascia [Figure 1]. Therefore, the patient was diagnosed with a renal parenchymal infection.

Figure 1: Computed tomography scan, showing a distended left kidney with perirenal exudation and thickening of the perirenal fascia

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After admission, the patient was administered a continuous subcutaneous insulin infusion to control his glucose concentration, and meropenem was used to treat the infection. His fasting blood glucose concentration was maintained in the range of 5–6 mmol/L and the postprandial blood glucose was maintained in the range of 7–8 mmol/L. Twelve days following diagnosis, the patient's blood count, procalcitonin, C-reactive protein, sedimentation rate, and liver enzymes had returned to normal, and his creatinine had improved to 105.9 μmol/l. The meropenem was replaced by ceftriaxone tazobactam because of the improvements in the laboratory parameters. A repeat CT scan performed on day 13 revealed an abscess in the left kidney, as evidenced by a thick-walled cavity filled with gas, accompanied by surrounding exudate and thickened fascia [Figure 2]. Therefore, CT-guided percutaneous renal puncture drainage was immediately performed and 300 ml of turbid fluid was drained. E. coli was cultured from the pus, and this was found to be sensitive to cephalosporins, including ceftriaxone tazobactam. The patient's inflammatory markers and urinalysis results gradually returned to normal (creatinine, 101.4 μmol/L), and his abdominal pain had improved by day 14.

Figure 2: Computed tomography scan, performed 13 days after the diagnosis of emphysematous pyelonephritis, showing the formation of a thick-walled cavity filled with gas, surrounded by exudate and thickened fascia, in the left kidney

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A repeat CT scan on day 20 showed no improvement [Figure 3]. The urologist recommended left nephrectomy, but the patient refused and was discharged. Subsequently, his fasting and postprandial blood glucose concentrations were controlled between 5–6 mmol/L and 7–8 mmol/L, respectively, and his serum creatine was between 120 μmol/L and 140 μmol/L. Two further CT scans performed on days 30 and 60 showed no reductions in gas or necrotic tissue in the renal parenchyma [Figure 4] and [Figure 5]. Although the patient had no obvious abdominal pain, he experienced weight loss of 5 kg. A renal dynamic test was performed on day 60: the right kidney was visualized using renal dynamic imaging, but the left kidney could not be. The glomerular filtration rate (GFR) of the left kidney was 5.19 ml/min·1.73 m², whereas that of the right kidney was 30.47 ml/min·1.73 m². Therefore, 2 months after discharge, the patient was re-hospitalized for left nephrectomy. A perirenal abscess causing high tension in the renal capsule was identified intraoperatively, and the left kidney was very soft [Figure 6]. Histopathological examination revealed severe inflammation and necrosis of the renal pelvis, with fibrosis [Figure 7]. The patient recovered well after the surgery and remained alive 5 months later.

Figure 3: Computed tomography scan performed 20 days after the diagnosis, showing the left kidney, which contains a thick-walled gas-containing cavity

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Figure 4: Computed tomography scan performed 30 days after the diagnosis, showing a large amount of necrotic tissue and thinning of the renal cortex

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Figure 5: Computed tomography scan performed 60 days after diagnosis, showing a large amount of necrotic tissue

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Figure 6: The left kidney of the patient after removal, showing distension and a huge abscess

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Figure 7: Haematoxylin and eosin-stained sections of the left kidney, showing fibroblasts and numerous inflammatory cells. Original magnification ×200

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Results

To review the epidemiology, characteristics, and treatment of EPN, the PubMed database was searched for reports of EPN published within the last 18 years using the following keywords: EPN (all fields) or pyelonephritis (MeSH term). After filtering for unrelated results and duplicates, data from 43 patients reported in 39 publications between 2002 and 2020 were collected and analyzed [Table 1]. The characteristics and treatments of these patients are summarized in [Table 2].

Table 1: Clinical and demographic data extracted from case reports (n=43) of emphysematous pyelonephritis published between 2002 and 2020

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Table 2: Characteristics of 43 patients with emphysematous pyelonephritis reported between 2005 and 2020

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The mean age of the patients diagnosed with EPN was 59.0 ± 12.4 years, and approximately 88% (38/43) had diabetes. E. coli was the most common organism cultured (20 patients, 46%). The most frequent site was the left kidney (77%, 33/43), and bilateral renal involvement was noted in 30% (13/43) of the patients. A transplanted kidney was affected in 14% of the patients (6/43), and in eight patients (19%) multiple organs were involved. All 43 patients were treated with antibiotics, the most common of which was meropenem. Because of a poor response to antibiotics, 37% of the patients (16/43) eventually required nephrectomy. The overall mortality rate associated with the EPN was 26% (11/43), but the mortality rate of the patients who underwent surgical treatment (19%, 3/16) was lower than that of patients who underwent conservative treatment (30%, 8/27). Of the patients who had EPN involving multiple sites according to radiological imaging, 29% (5/17) died. The mortality rate was 83% (5/6) among patients who had undergone kidney transplantation.

Discussion

EPN is a rare, life-threatening disease that was first reported by Kelly and MacCallum in 1898^[43] as renal emphysema. The nomenclature “emphysema pyelonephritis” was introduced by Schultz and Klorfein in 1962.^[44] EPN is often associated with severe sepsis, which has a mortality rate as high as 40%–50%.^[45] In the present study, the mortality rate calculated was slightly lower than that reported in the literature, likely because of the prompt use of antibiotics and early surgery in recent years. EPN is more likely to occur in patients with diabetes because their high blood glucose concentrations provide nutrition for the bacteria. We found that 88% of the reported patients with EPN had diabetes. Misgar et al.^[46] analyzed the characteristics of 26 patients with EPN in a single-center study, all but two of whom were women. Previous studies have shown that women have a higher prevalence of EPN because of their greater susceptibility to urinary tract infection.^[47] The only caveat to this predisposition is that men who undergo renal transplantation are more likely to develop EPN,^[48] and this is consistent with the results of the present analysis.

CT is considered the most appropriate means of diagnosing EPN. The accumulation of gas can be rapid and is always indicative of persistent infection and the inefficacy of treatment.

Despite increasing awareness of EPN and greater diagnostic accuracy in recent years, the most appropriate treatment is controversial. The conventional treatment for patients with severe disease is nephrectomy;^[4] however, this has been gradually replaced by drainage via the percutaneous catheter.^[9] We found that the mortality rate of patients who underwent surgery is lower than that of patients who only undergo conservative treatment. We also found that patients with a history of renal transplantation or involvement of more than two sites, such as both kidneys, were more likely to die than those of patients with unilateral kidney infection. This implies that renal transplantation and multi-organ involvement are risk factors for mortality.

In summary, we have described the clinical course of a patient with EPN who did not respond to conservative treatment, and summarized the available literature concerning EPN. We found that EPN occurred more frequently and was associated with a higher mortality rate in patients with diabetes. E. coli is the most common pathogen. The surgical treatment of EPN is associated with a lower mortality rate than conservative treatment. Finally, the mortality rate is higher in patients who had undergone transplantation or showed multi-site involvement on radiological imaging.

Our experience highlights the importance of commencing antibiotic treatment as soon as EPN is diagnosed. Furthermore, when renal parenchymal necrosis is identified, CT-guided percutaneous renal puncture drainage should be performed because this rapidly improves kidney function. We have also demonstrated the value of CT and renal function tests for the evaluation of the efficacy of conservative treatment during the course of the disease. If there is a significant decrease in renal GFR, or the accumulation of gas and necrotic tissue in the kidney parenchyma on CT worsens or does not improve, nephrectomy should be performed as soon as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Mark Cleasby, PhD from Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the language of a draft of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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