Introduction: Emphysematous pyelonephritis(EPN) is a necrotizing infection of the renal parenchyma. Most cases occur in the setting of uncontrolled diabetes mellitus(DM). Presentation ranges from mild symptoms to shock and altered sensorium.
Objective: To highlight efficacy of intensive, appropriate medical therapy in management of a rare but life-threatening infection.
Case presentation: A 54-year old man presented with 3 week history of fever and left flank pain. A week earlier, he had developed cough and pleuritic chest pain. The patient was diagnosed with DM in current illness. On examination, he was acutely ill-looking, febrile(T38.9oC), dehydrated, with bilateral pedal oedema. He had tachycardia, tachypnea, coarse crepitation left lower lung zone, and left renal angle tenderness. Investigations: Random blood glucose 329 mg/dl, white blood count 26 026 cells/mm3 with neutrophilia, anaemia (PCV26%), elevated ESR (112 mm/h) and azotaemia. Abdominopelvic CT scan showed multiple air densities in the left kidney, perinephric abscess, pleural effusion with passive atelectasis in left lower lung. Diagnosis was EPN (Class 3A) in Type 2 DM, complicated by pleural effusion and atelectasis. Intravenous fluids, antibiotics, insulin and supportive therapy were commenced. He made steady improvement in clinical and laboratory parameters; subsequently discharged to clinic.
Discussion: EPN is a potentially fatal bacterial infection. Gas accumulation in renal tissues suggests the diagnosis. It occurs mostly in uncontrolled, middle-aged, diabetic patients, with a female preponderance. Surgical interventions ranging from drainage to nephrectomy have been considered choice treatment. As in index patient, however, intensive medical treatment yields favourable outcomes, reducing nephrectomy rates. Surgery should not be delayed in patients unresponsive to medical therapy.
Conclusion: Intensive medical therapy is a reasonable option in management of EPN. This limits frequency of nephrectomy in patients.