Emphysematous Pyelonephritis: When Minimally Invasive Approaches are not Enough

Special Article – Urinary Tract Infections

Austin J Clin Med. 2015;2(1): 1021.

Emphysematous Pyelonephritis: When Minimally Invasive Approaches are not Enough

Cornejo-Dávila V¹*, Cantellano-Orozco M¹, Martínez-Arroyo C¹, Morales-Montor JG¹ and Pacheco-Gahbler C¹

¹Division of Urology, Hospital General “Dr. Manuel Gea González”, Mexico

*Corresponding author: Cornejo-Dávila V, Division of Urology, Hospital General “Dr. Manuel Gea González”, Calzada de Tlalpan 4800 Col, Sección XVI, Tlalpan, Zip code: 14080, Mexico

Received: January 16, 2015; Accepted: March 04, 2015; Published: April 15, 2015


The author presents a case of a diabetic patient that developed a severe left emphysematous pyelonephritis manifested by septic shock that was managed initially with minimally invasive techniques with percutaneous drainage and wide-spectrum antibiotics. Besides her clinical improvement the gas wasn’t resolved entirely even after a second percutaneous drainage and eventually ended in a simple nephrectomy due to persistent fever. What would seem like a pretty common management for this clinical entity, nowadays it represents the exception rather than the rule. This case exemplifies how even though the minimally invasive approaches are used to spare the kidney, a nephrectomy still plays a role in the management of patients with this complicated infection.

Keywords: Emphysematous pyelonephritis; Nephrectomy; Minimally invasive; Mexico


UTI: Urinary Tract Infection; CT: Computed Tomography; EPN: Emphysematous Pyelonephritis


Urinary tract infections comprehend a wide spectrum of presentations that can vary from mild clinical pictures such as noncomplicated cystitis to life-threatening conditions with extensive tissue destruction such as emphysematous pyelonephritis. An emphysematous pyelonephritis represent a gas-producing infection developed by gram negative bacteria that metabolize the excess of carbohydrates (mainly glucose) with formation of carbon dioxide, that starts to accumulate in the urinary tract and collecting systems; this gas later extends through the renal parenchyma and can reach the perinephric and even pararenal space. These patients usually develop sepsis and/or septic shock, and often require intensive care support associated with high mortality [1]. They require wide spectrum antibiotics [2] and a minimally invasive procedure to drain the gas and/or purulent material on most cases. In the past a nephrectomy was performed frequently in early stages of the disease, which lead to a greater overall and trans-surgical mortality due to sepsis and bleeding by trying to dissect a heavily inflamed kidney and surrounding structures [3]. To avoid an increased morbidity, the use of minimally invasive treatments such as percutaneous drainage and ureteral stents replaced the other approaches [4,5] however, there are infections that won’t resolve with these treatments and patients will eventually need a nephrectomy to achieve a cure. We present a case of emphysematous pyelonephritis that exemplifies that situation.

Case Presentation

A 48-year-old woman arrived to the emergency department with a one-week history of fever, malaise, nausea and left flank pain. She had a history of diabetes and hypertension with poor control and had been hospitalized six months previously for a urinary tract infection that was treated empirically with quinolones at a community hospital. She had no follow-up and no cultures taken. On admission she was diagnosed with septic shock, diabetic ketoacidosis and renal failure; after being resuscitated with intravenous fluids and started on inotropes and insulin infusion protocol, wide-spectrum antibiotics (ertapenem and amikacin adjusted to renal function) were also initiated. Once being stable an abdominal computed tomography was performed (Figure 1) establishing a diagnosis of left emphysematous pyelonephritis Huang 3b with extension of the gas throughout Gerota’s fascia on the lower pole. Forty-eight hours after admittance an image-guided percutaneous drainage with a 10 French catheter was performed (Figure 2A and 2B) obtaining gas and 100 mL of purulent material; the catheter was left on continuous suction. An extended-spectrum betalactamases-producing E.coli strain with resistance to quinolones and trimethoprim was isolated from the obtained material as well as in a blood culture. She had a slow improvement with an average of 50 mL of purulent material drained per day; one week after admission the sepsis and renal failure had remitted but the gas persisted on a follow-up CT (Figure 2C and 2D). Given those findings a second image-guided percutaneous drainage was done obtaining more gas and scarce purulent material. On the thirteenth inpatient day, her evolution was stationary, persisting with spikes of fever and gas on lower renal pole with distortion of renal parenchyma’s anatomy was observed on another CT despite the catheter (Figure 3). The decision of performing an open simple nephrectomy was made, with findings of an intense perinephric inflammatory reaction and purulent material within the kidney; chronic pyelonephritis with abscess and multifocal necrosis was reported on the pathological report. After the procedure she remained non-febrile and was discharged on postoperatory day 3. On follow-up at the urology clinic she was doing well, had a negative urine culture, normal glycemia and normal creatinine levels.