V07_No_4.pdf


Pictorial Urology

225Urology Journal   Vol 7   No 4   Autumn 2010

Gas in the Renal Area
Emphysematous Pyelonephritis

Urol J. 2010;7:225.
www.uj.unrc.ir

A 37-year-old diabetic woman presented to the 
emergency department with a week’s history of 
high fever, abdominal pain, and vomiting. She was 
febrile, tachypneic, tachycardic, and hypotensive. 

Her laboratory investigations revealed a total 
lymphocyte count of 6000/cu mm, with 6% band 
forms and 87% neutrophils. Her platelet count 
and creatinine level were 15 000/cu mm and 2.6 
mg/dL, respectively. Her blood and urine cultures 
were positive for Escherichia coli.

Arterial blood gas revealed metabolic acidosis. 
Plain x-ray of the abdomen showed a reniform 
shaped presence of air in the right renal area. A 
diagnosis of emphysematous pyelonephritis was 
made based on the classical presence of air within 
the kidney. 

She underwent initial hemodynamic 
stabilization and a bedside placement of a 
percutaneous nephrostomy along with culture-
specific parenteral antibiotics. With the above 
conservative measures, she dramatically improved 
and had a normal creatinine (1.1 mg/dL) ten days 
later at discharge.

The treatment of emphysematous pyelonephritis 
has undergone a paradigm shift, from 
nephrectomy to percutaneous drainage and 
antibiotics. There are a number of studies which
substantiate that even in the more serious forms 
(viz., Class 3/4), percutaneous drainage along with 
appropriate parenteral antibiotics are sufficient. (1)
Predictors of mortality in this disease are 
thrombocytopenia, shock, altered sensorium, and 
ongoing need for dialysis.(2)

Although our patient had two of the four poor 
prognostic factors at presentation, she improved 
remarkably with bedside drainage, highlighting 
the importance of early diagnosis and prompt 
treatment. This image stresses the need to 
aggressively investigate the unresolved case of an 
acute abdomen.

John Samuel Banerji
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: johnsbanerji2002@yahoo.co.in

REFERENCES
1. Somani BK, Nabi G, Thorpe P, Hussey J, Cook J, N’Dow J. Is percutaneous drainage the new gold standard in the 

management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008;179:1844-9.

2. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome 
of conservative management. Urology. 2008;71:1007-9.