Urology Journal UNRC/IUA Vol. 1, No. 4, 282-283 Autumn 2004 Printed in IRAN 282 Successful Medical Treatment of Emphysematous Pyelonephritis ASGARI SA* Departement of Urology, Razi Hospital, Gilan University of Medical Sciences, Rasht, Iran KEY WORDS: emphysematous pyelonephritis, percutaneous nephrostomy, nephrectomy, medical treatment Introduction Emphysematous pyelonephritis (EPN) is a rare life threatening condition. It usually happens in diabetic patients. Its mortality is as high as 75% and urgent nephrectomy has been highly recom- mended.(1) However, recent advancements in imaging tech- niques and new stronger antibiotics can make medical treatment an acceptable alternative for radical surgery. We report a diabetic patient with EPN, who was managed successfully with medical treatments. Case Report A 45-year-old woman with a history of fever for 10 days, persistent left flank pain, nausea, vomit- ing, and loss of appetite was referred to our med- ical center. She was also complaining of irritative urinary symptoms. Hematuria or pneumaturia was not present. She had non-insulin dependent diabetes mellitus for 12 years, which was under control with glibenclamide and metformine. She had also a history of myocardial infarction 3 months earlier. On admission, she was cachectic and ill. The conjunctiva was pale and the other vital signs were as follows: blood pressure: 130/85 mmHg, pulse rate = 90/min, and Temp = 38.1°C. On physical examination, the left flank was ten- der and a moderately mobile and soft mass was palpable. The right kidney was also palpable, but without tenderness. Laboratory studies revealed leukocy- tosis, anemia, serum creatinine 2.5 mg/dl, pyuria, and microscopic hematuria. Left kidney calyxes were outlined in KUB. On intravenous pyelography that had been taken in another center, the left kidney was not visible, but there was air in the collecting system and the resultant air pyelogram and ureterogram were apparent (fig. 1). Ultrasonography revealed diffuse echogenic foci in the left kidney, together with hydronephrosis and dirty shadow. In addi- tion, there was a 17-mm echogenic focus behind the bladder in the left side (suggestive of stone). Due to the history of myocardial infarction 3 months earlier, the risk of surgery was high, and we decided to attempt medical treatment. CT scan without contrast enhancement revealed an enlarged left kidney with air density in collecting system (fig. 2). Under intravenous sedation with neuroleptic agents and antibiotic coverage, cystoscopy and ureteroscopy were done. There was not any obstruction in the left ureter, but after lifting a mucosal fold, a purulent discharge was seen. Left percutaneous nephrostomy was performed and a ureteral stent was placed in the left ureter. After Received February 2003 Accepted May 2004 *Correspondng author: Department of Urology, Razi hospital, Sardar-e-Jangal St., Rasht, Iran. Tel: +98 911 132 0117, E-mail: s-a-asgari@gums.ac.ir. FIG. 1. Air pyelogram and ureterogram in the collecting system was detected by intravenous pyelography. Asgari 283 24 hours, nephrostomy tube was removed due to cessation of discharge. Antibiotic therapy consist- ed of metronidazole 500 mg, IV, TID, ceftriaxone 1 gr, IV, BD. After seven days of medical treat- ment, the patient's fever was alleviated and serum creatinine level decreased to normal level. The patient was discharged in the tenth day of admission with a good general condition and oral antibiotic (ciprofloxacin 500mg, PO, BD) for addi- tional five days was priscribed. Discussion Emphysematous pyelonephritis was first described in 1898 as an acute perirenal narcotiz- ing parenchymal infection that is produced by gas forming uropathogen. Patients with EPN are very ill and septic and some have associated liver insufficiency.(1) Mostly it is unilateral, but in 10% of cases, both kidneys are involved. Four factors have been proposed to have a role in the develop- ment of EPN: gas producing bacteria, high blood glucose level, damaged tissue perfusion, and impaired immune response. In a report of 48 patients with EPN, 96% were diabetics and 22% had urinary obstruction. The most common causative microorganisms are: Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Aerobacter aerogenes, Citrobacters, and rarely fungi.(2) Emphysematous pyelonephritis can be fatal if left untreated. Traditionally the consensus is that mere medical treatment is ineffective and prompt nephrectomy is necessary. Mortality rate in patients who are treated only with antibiotics is 40%. Treatment is successful in 66% of patients who are treated with percutaneous nephrostomy and antibiotics, and in 90% of those with nephrec- tomy. Man et al have divided the EPN into two types.(3) In type one that is a classic from of EPN, the gas is disseminated throughout the kidney in the form of streaky or mottled pattern and there is associated tissue destruction and little or nil fluid.(4) In type two, there is fluid collection in renal or perirenal tissues with gas accumulation in collecting system (fig. 1). In type one, due to severe tissue destruction, the prognosis is poor and it is recommended that nephrectomy must be done. In type two, like our patient, prognosis is better and one can expect appropriate response to medical therapy.(5,6) Based on our findings, it seems that nephrecto- my is not a preferred treatment for all of the EPN cases. Nowadays, there are growing reports of successful medical treatment of EPN. References 1. Eloubeidi MA, Fowler VG Jr. Images in clinical medicine. Emphysematous pyelonephritis. N Engl J Med. 1999;341:737. 2. Gervais DA, Whitman GJ. Emphysematous pyelonephri- tis. AJR Am J Roentgenol. 1994;162:348. 3. Man YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-produc- ing bacterial renal infection: correlation between imag- ing findings and clinical outcome. Radiology. 1996;198:433-8. 4. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, progno- sis, and pathogenesis. Arch Intern Med. 2000; 160: 797- 805. 5. Best CD, Terris MK, Tacker JR, Reese JH. Clinical and radiological findings in patients with gas forming renal abscess treated conservatively. J Urol. 1999;162:1273-6. 6. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83:149-54. FIG. 2. Enlarged edematous left kidney with air density in the collecting system was observed in CT scan without contrast enhancement.