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Conservative management of emphysematous pyelonephritis.

Laway BA, Bhat MA, Bashir MI, Ganie MA, Mir SA, Daga RA - Indian J Endocrinol Metab (2012)

Bottom Line: Emphysematous pyelonephritis, though uncommon, is a severe necrotizing kidney infection common in patients with diabetes.Surgical treatment has been advocated as the treatment of choice in most of the patients.We present the clinical course of an elderly lady who presented with emphysematous pyelonephritis and was successfully managed with medical treatment despite the presence of adverse prognostic factors like acute renal failure and thrombocytopenia.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.

ABSTRACT
Emphysematous pyelonephritis, though uncommon, is a severe necrotizing kidney infection common in patients with diabetes. Surgical treatment has been advocated as the treatment of choice in most of the patients. We present the clinical course of an elderly lady who presented with emphysematous pyelonephritis and was successfully managed with medical treatment despite the presence of adverse prognostic factors like acute renal failure and thrombocytopenia.

No MeSH data available.


Related in: MedlinePlus

(a) Non-contrast CT (NCCT) of abdomen at admission revealing gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter suggestive of EPN; (b) NCCT on the 5th day revealing decrease in the size and extent of EPN; (c) NCCT after 3 weeks revealing complete disappearance of features of EPN
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Figure 1: (a) Non-contrast CT (NCCT) of abdomen at admission revealing gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter suggestive of EPN; (b) NCCT on the 5th day revealing decrease in the size and extent of EPN; (c) NCCT after 3 weeks revealing complete disappearance of features of EPN

Mentions: A 70-year-old woman presented with 4-day history of fever, right flank pain, polyurea, and altered sensorium. She had been detected to have diabetes mellitus about a month back and was taking oral antidiabetic medication. The patient was ill looking, agitated, and talking irrelevant; she was febrile (temperature 100°F) and tachypnic (respiratory rate 34 per minute); her heart rate was 110 bpm and blood pressure was 90/60 mmHg. On systemic examination, air entry was reduced and crepitations were audible more on the right side; suprapubic and right renal angle tenderness was present and no abdominal mass was palpable. There was no neurodeficit or localizing sign. Initial laboratory evaluation included complete blood count (hemoglobin 9.9 g%, total leukocyte count 9500/μl with 86% neutrophils, and platelet count of 36,000/μl), kidney function tests (blood urea 95 mg/dl and serum creatinine 4.6 mg/dl), random blood glucose (408 mg/dl) and arterial blood gas analysis (pH 7.37, SaO2 89.5%, PCO2 18.3 mmHg, PO2 56.4 mmHg, and HCO3 10.4 meq/l). Numerous pus cells were seen on urine microscopic examination while ketones were absent. Bilateral pleural effusion was evident on posterioanterior chest radiograph and electrocardiogram showed sinus tachycardia. USG abdomen revealed left kidney size of 11.1 × 4.4 cm with mild increased echo pattern. Right kidney was 11 × 4.7 cm, showing dense acoustic shadow. NCCT of brain was normal; cerebrospinal fluid examination, performed in view of altered sensorium, was normal. Repeated urine and blood culture samples taken during the hospital stay failed to grow any organism. Computed tomography (CT) of the abdomen revealed the presence of gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter. Left kidney was normal [Figure 1a]. The diagnosis of EPN was made and the patient was managed with oxygen inhalation, intravenous fluids in the form of normal saline, and insulin infusion to achieve euglycemia. Empiric intravenous antibiotics in the form of pipericillin, tazobactum, and metronidazole were administered. Because of persistent fever, hypotension and worsening renal functions, the antibiotic spectrum was broadened in the form of addition of ciprofloxacin and vancomycin. Ionotropic support with dopamine was also initiated after the 2nd day. The patient's clinical condition started improving around the 4th day of treatment and NCCT on the 5th day revealed marked improvement in the form of decrease in the size and extent of EPN [Figure 1b]. The patient made a remarkable recovery over the next 2 weeks. After 3 weeks, another NCCT abdomen revealed complete disappearance of features of EPN [Figure 1c]. After this, parenteral antibiotics were stopped and the patient was put on oral third-generation cephalosporin (cefpodoxime proxitel + clavulanate) and ciprofloxacin. She recovered completely [Table 1]. She was on oral diet and was discharged on two doses of premixed (30/70) insulin at the end of 4 weeks. When reviewed after two more weeks, the patient was asymptomatic and routine urine examination was normal. She was prescribed metformin 1 g/day with good glycemic control.


Conservative management of emphysematous pyelonephritis.

Laway BA, Bhat MA, Bashir MI, Ganie MA, Mir SA, Daga RA - Indian J Endocrinol Metab (2012)

(a) Non-contrast CT (NCCT) of abdomen at admission revealing gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter suggestive of EPN; (b) NCCT on the 5th day revealing decrease in the size and extent of EPN; (c) NCCT after 3 weeks revealing complete disappearance of features of EPN
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3313756&req=5

Figure 1: (a) Non-contrast CT (NCCT) of abdomen at admission revealing gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter suggestive of EPN; (b) NCCT on the 5th day revealing decrease in the size and extent of EPN; (c) NCCT after 3 weeks revealing complete disappearance of features of EPN
Mentions: A 70-year-old woman presented with 4-day history of fever, right flank pain, polyurea, and altered sensorium. She had been detected to have diabetes mellitus about a month back and was taking oral antidiabetic medication. The patient was ill looking, agitated, and talking irrelevant; she was febrile (temperature 100°F) and tachypnic (respiratory rate 34 per minute); her heart rate was 110 bpm and blood pressure was 90/60 mmHg. On systemic examination, air entry was reduced and crepitations were audible more on the right side; suprapubic and right renal angle tenderness was present and no abdominal mass was palpable. There was no neurodeficit or localizing sign. Initial laboratory evaluation included complete blood count (hemoglobin 9.9 g%, total leukocyte count 9500/μl with 86% neutrophils, and platelet count of 36,000/μl), kidney function tests (blood urea 95 mg/dl and serum creatinine 4.6 mg/dl), random blood glucose (408 mg/dl) and arterial blood gas analysis (pH 7.37, SaO2 89.5%, PCO2 18.3 mmHg, PO2 56.4 mmHg, and HCO3 10.4 meq/l). Numerous pus cells were seen on urine microscopic examination while ketones were absent. Bilateral pleural effusion was evident on posterioanterior chest radiograph and electrocardiogram showed sinus tachycardia. USG abdomen revealed left kidney size of 11.1 × 4.4 cm with mild increased echo pattern. Right kidney was 11 × 4.7 cm, showing dense acoustic shadow. NCCT of brain was normal; cerebrospinal fluid examination, performed in view of altered sensorium, was normal. Repeated urine and blood culture samples taken during the hospital stay failed to grow any organism. Computed tomography (CT) of the abdomen revealed the presence of gas in the right pelvicalyceal system and renal parenchyma, with air and debris in dilated right ureter. Left kidney was normal [Figure 1a]. The diagnosis of EPN was made and the patient was managed with oxygen inhalation, intravenous fluids in the form of normal saline, and insulin infusion to achieve euglycemia. Empiric intravenous antibiotics in the form of pipericillin, tazobactum, and metronidazole were administered. Because of persistent fever, hypotension and worsening renal functions, the antibiotic spectrum was broadened in the form of addition of ciprofloxacin and vancomycin. Ionotropic support with dopamine was also initiated after the 2nd day. The patient's clinical condition started improving around the 4th day of treatment and NCCT on the 5th day revealed marked improvement in the form of decrease in the size and extent of EPN [Figure 1b]. The patient made a remarkable recovery over the next 2 weeks. After 3 weeks, another NCCT abdomen revealed complete disappearance of features of EPN [Figure 1c]. After this, parenteral antibiotics were stopped and the patient was put on oral third-generation cephalosporin (cefpodoxime proxitel + clavulanate) and ciprofloxacin. She recovered completely [Table 1]. She was on oral diet and was discharged on two doses of premixed (30/70) insulin at the end of 4 weeks. When reviewed after two more weeks, the patient was asymptomatic and routine urine examination was normal. She was prescribed metformin 1 g/day with good glycemic control.

Bottom Line: Emphysematous pyelonephritis, though uncommon, is a severe necrotizing kidney infection common in patients with diabetes.Surgical treatment has been advocated as the treatment of choice in most of the patients.We present the clinical course of an elderly lady who presented with emphysematous pyelonephritis and was successfully managed with medical treatment despite the presence of adverse prognostic factors like acute renal failure and thrombocytopenia.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.

ABSTRACT
Emphysematous pyelonephritis, though uncommon, is a severe necrotizing kidney infection common in patients with diabetes. Surgical treatment has been advocated as the treatment of choice in most of the patients. We present the clinical course of an elderly lady who presented with emphysematous pyelonephritis and was successfully managed with medical treatment despite the presence of adverse prognostic factors like acute renal failure and thrombocytopenia.

No MeSH data available.


Related in: MedlinePlus