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Pneumo-pyelo-calico-ureter

We report a case of EPN diagnosed behind a Pneumo-pyelo-calico-ureter on plain X ray and confirmed on the CT scan. 

Authors: Y. El harrech, H, Jira, J. Chafiki, A. Ameur, M. Abbar. Department of urology, military hospital Mohamed V, Rabat, Morocco
 
Corresponding Author: Dr Younes EL HARRECH, departement of urology, HMIMed V, Rabat, Morocco. E- mail: [email protected]

 

Abstract
Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection of the renal parenchyma and perirenal tissue, characterized by gas formation. This rare disorder tends to occur more frequently in patients with diabetes mellitus and urinary tract obstruction. We report a case of EPN diagnosed behind a Pneumo-pyelo-calico-ureter on plain X ray and confirmed on the CT scan.

 

Introduction
Emphysematous pyelonephritis (EPN) is an acute life-threatening bacterial infection. EPN leads to rapid necrotizing destruction of the renal parenchyma and peri-renal tissue, requiring early and aggressive care to reduce morbidity and mortality. To our knowledge, this is the first report of pneumo-pyelo-calico-ureter caused by EPN.

 

Case report
A, 39 years old female, with no known history of diabetes mellitus presented to the emergency room with right flank pain, fever and chills.
Initial vital signs showed a temperature of 38°C, pulse was 108 beats per minute, blood pressure was 81/51 mm Hg, and respiratory rate was28 breaths per minute. Physical examination was remarkable only for pallor, and the patient was slightly disoriented. The right lumbar region was painful without crackles. After resuscitation with saline infusion and dopamine, the blood pressure rose to 100/60 mmHg. Laboratory tests showed a white blood cell count of 14100 / mm3, haemoglobin at 10 g/dl, platelet count at 111000/100ml, serum creatinine 40 mg/l and blood sugar  4 g/l. Urinary strips showed diabetic ketoacidosis with 3 + of sugar and 3 + of ketones.
Plain X ray showed a pneumo-pyelo-calico- ureter (Figure 1).

 

Figure 1:  Plain X ray showing a pneumo-pyelo-calico- ureter

 

Computed tomography showed air in the right retroperitoneal space and in the renal parenchyma, along with anair-filled renal pelvis and ureter (Figure 2). No stone was seen.

 

Figure 2: Computed tomography revealed showed air in the right retroperitoneal space, in the renal parenchyma and air-filled renal pelvis and ureter.

 
The diagnosis of emphysematous pyelonephritis was made. Initially, ciprofloxacin 400 mg IV twice daily was given as empiric treatment. Urgent nephrectomy was done via a lumbotomy. After surgery, strict control of diabetes with insulin was obtained.Intensive antibiotic therapy was administered. Improvement in the patient’s general state was rapid and she was  apyrexial within 24 hours. Bacterial analysis (blood, urine, renal parenchyma) showed the presence of an Escherichia coli susceptible to fluoroquinolones, which were continued. The patient left the hospital on the 5th day after surgery,with insulin therapy. The histology of the surgical specimen concluded acute suppurated pyelonephritis with papillary necrosis and vascular thrombosis.

 

Discussion
Emphysematous pyelonephritis (EPN) is an uncommon but life-threatening acute, severe, necrotizing infection of the renal parenchyma and surrounding areas, characterized by the presence of gas within the renal parenchyma, collecting system, and or perinephric tissue.
EPN was first described in 1898; in association with pneumaturia as a result of gas-forming pathogens [1]. EPN deserves special attention because of its septic complications with life-threatening potential. It has been associated with severe morbidity and mortality [2, 3]. EPN is caused by gas-forming organisms and almost always occurs in patients with uncontrolled diabetes mellitus (DM), with or without obstructive uropathy. The most common pathogen is Escherichia coli (70%), followed by Klebsiella pneumoniae (29%) and Proteus spp. [4]. In cases of proven EPN, abdominal radiography (plain film of the ureter, kidney, and bladder) identifies gas in only two thirds of patients. Only one case of pneumoureter is reported in published literature [5], so far as we are aware. In our case the gas was present in calices, pelvis and ureter.
Renal USS can confirm the presence of EPN in approximately 80% of cases [6], whereas CT is 100% sensitive [7]. Traditionally, management of EPN is aggressive, and surgery is mandatory. Recent literature, however, demonstrates that for selected patients with less severe disease, antibiotic therapy along with percutaneous drainage may be effective [8].

 

Conclusion
Rapid and thorough assessment, prompt diagnosis and appropriate aggressive treatment is likely to reduce mortality in EPN. In the acute abdomen, particularly in patients suffering from diabetes mellitus, the plain X ray should specifically be reviewed to look for gas in the collecting system and exclude signs of all general surgical diagnoses.

 

References
1. Kelly HA, MacCallum WG: Pneumaturia. JAMA 1898; 31: 375-81
2. Tang HJ, Li CM, Yen MY, et al: Clinical characteristics of emphy sematous pyelonephritis. J Microbiol Immunol Infect 2001; 34: 125-130
3. Park BM, Lee SJ, Kim YW, et al: Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scan J Urol Nephrol 2006; 40: 332-338
4. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T: Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology1997; 49: 343-6
5. Chung SD, Sun HD, Weng WC, Chiu B, Peng FS. Pneumoureter. Int J Infect Dis. 2009 Mar;13(2):e79-80.
6. Tang HJ, Li CM, Yen MY, Chen YS, Wann SR, Lin HH, et al.: Clinical characteristic of emphysematous pyelonephritis. J Microbiol Immunol Infect  2001; 34: 125-30
7. Ahlering TC, Boyd SD, Hamilton CL, et al.: Emphysematous pyelonephritis: a five year experience with 13 patients. J Urol 1985; 134: 1086-1088
8. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008; 71: 1007-9

 

Date added to bjui.org: 26/04/2011


DOI: 10.1002/BJUIw-2011-017-web

 

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