Clinical picture

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Dec 17, 2009 - Clinical picture. Emphysematous pyelonephritis, ureteritis and cystitis in a diabetic patient. An 81-year-old Taiwanese woman presented to our.
Q J Med 2010; 103:893–894 doi:10.1093/qjmed/hcp180 Advance Access Publication 17 December 2009

Clinical picture Emphysematous pyelonephritis, ureteritis and cystitis in a diabetic patient pyelonephritis is a rare, life-threatening, suppurative infection of renal parenchyma and peri-renal tissue. These infections are often rapidly progressive and occasionally fatal.1 Escherichia coli and Klebsiella pneumoniae are the most common pathogens.2,3 Women outnumbered men and most patients had diabetes mellitus.2 The overall mortality rate of emphysematous urinary tract infection was high, even with drainage or surgical intervention.2,4

Figure 1. Abdominal radiography showed air distribution in the collecting system of right kidney, right ureter, and around the urinary bladder (arrows).

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An 81-year-old Taiwanese woman presented to our emergency department because of a 2-day history of lower abdomen pain. She also complained nausea and general weakness, but denied fever, diarrhea or black stool. She was known case of type 2 diabetes mellitus on oral anti-diabetic agents for the past 10 years with poor diabetic control. In addition, she experienced an episode of cerebral vascular accident in recent 1 year. Physical examination showed well-orientated consciousness, her body temperature 358C, pulse rate 79 per min, respiratory rate 20 per min and blood pressure 98/47 mmHg. Her bowel sound was normoactive. Her lower abdomen was tender without muscle guarding or rebound tenderness. Laboratory data revealed as the followings: white blood count 27550 IU/l with a neutrophilic segment of 94.2% and C-reactive protein 36.15 mg/dl. Urine analysis revealed turbid appearance with obvious pyuria and hematuria. Abdominal radiography demonstrated linear air distribution along the collecting system of right kidney, right ureter and around the urinary bladder (UB) (Figure 1, arrows). Abdominal computed tomography demonstrated the presence of air in the UB wall, right ureter and collecting system of right kidney (Figure 2A and B, arrows). Emphysematous pyelonephritis, ureteritis and cystitis were diagnosed on the basis of radiological characteristics. She developed septic shock and acute respiratory failure; she then was treated with intubation and broad-spectrum antibiotics. After conservative treatment, her condition became stable and without percutaneous drainage or surgical treatment. Emphysematous urinary tract infection is the result of necrotizing inflammation which was caused by gas-forming organisms with gas formation within the renal parenchyma, collecting system or UB, including emphysematous cystitis, emphysematous ureteritis and emphysematous pyelonephritis. Among above diseases, emphysematous

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Clinical picture

In the treatment of emphysematous urinary tract infection, appropriate medical treatment should be initiated, including systemic antibiotics and wellcontrol diabetic, etc. and immediate drainage or surgical intervention should not be delayed.4 Photographs and text from: W.-C. Liao and J.-W. Chou, Department of Internal Medicine, China Medical University Hospital, #2, Yuh-Der Road, North District, Taichung 40447, Taiwan. email: [email protected] Conflict of interest: None declared.

References 1. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment, and survival. Am J Med Sci 2007; 333:111–6. 2. Hung JJ, Tseng CC. Emphysematous pyelonephritis clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797–805. 3. Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int 2007; 100:17–20. 4. Tang HJ, Li CM, Yen MY, Chen YS, Wann SR, Lin HH, et al. Clinical characteristics of emphysematous pyelonephritis. J Microbiol Immunol Infect 2001; 34:125–30.

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Figure 2. Abdominal computed tomography. A, air in the collecting system of right kidney (arrows); B, air in the wall of urinary bladder and right ureter (arrows).