Diabetic Ketoacidosis Triggered by an Emphysematous Urinary Tract Infection: A Case Report and Mini-Review of Literature

Case Report

J Fam Med. 2021; 8(5): 1259.

Diabetic Ketoacidosis Triggered by an Emphysematous Urinary Tract Infection: A Case Report and Mini-Review of Literature

Buenrostro-Valenzuela JC¹, Amezquita-Perez J², Schlie-Villa W² and Romero-Bermudez J¹*

¹Department of Internal Medicine, Mexico´s General Hospital “Dr Eduardo Liceaga”, Mexico

²Department of Cardiology, National Medical Center “La Raza” Specialties’ Hospital “Antonio Fraga Mouret” (IMSS), Mexico

*Corresponding author: Romero-Bermudez J, Department of Internal Medicine, Mexico´s General Hospital “Dr Eduardo Liceaga”, 148 Dr Balmis, Mexico

Received: May 25, 2021; Accepted: June 23, 2021; Published: June 30, 2021


Generally, the most common triggers for Diabetic Ketoacidosis (DKA) are infectious diseases, such as Urinary Tract Infections (UTIs) or pneumonia. However, emphysematous infections are significant diseases rarely associated with DKA. Here, we present two cases of emphysematous urinary tract infection associated to diabetic ketoacidosis, highlighting the importance of a timely intervention and treatment. We review the need for appropriate laboratory and image testing in the context of infected patients who do not reach inflammatory/ glycemic goals to diagnosticate complicated infectious processes. This case report and mini-review also explore pathophysiology, the association of DKA and urinary emphysematous infections and treatment options.

Keywords: Diabetic ketoacidosis; Emphysematous pyelonephritis; Emphysematous cystitis


Emphysematous pyelonephritis is an acute necrotizing infection of the urinary tract and/or adjacent tissues, in which gas accumulation occurs within the collecting system, renal parenchyma, or surrounding tissue, depending on severity [1-3].

A higher prevalence in the female gender has been described, as well as an average age presentation of 60 years [2].

The main risk factors associated in case series in literature are: type 2 diabetes mellitus, in up to 95% of patients with emphysematous pyelonephritis have preceding deficient glycemic control, followed by urinary tract obstruction [2,3].

Most type 2 diabetes patients exhibit inadequate glycemic control levels upon admission confirmed by HbA1C levels greater than 8% or presence of microvascular complications (diabetic retinopathy/nephropathy) [2]. The pairing of diabetic ketoacidosis and emphysematous pyelonephritis is uncommon, this correlation is rare and few cases have been documented, being an important mortality outcome predictor [4,5]. In these cases, clinical or surgical treatment evidence is still lacking. However, successful conservative management has been reported despite metabolic decompensation in HUANG stages 2 or lower [6].

Among pathogenic agents, Escherichia coli is the most commonly cultured organism cultured, followed by Klebsiella pneumonia [2]. Clinical presentation is characterized by fever accompanied with abdominal pain (predominantly in flanks or lumbar region) as the most frequent symptoms, and may also be accompanied by nausea or vomiting [3].

Computed Tomography (CT) scan remains the modality of choice to demonstrate the presence of gas, distribution and extent of the disease. Making it the perfect image study to adequately classify this complicated infection. Furthermore, this test has treatment and prognosis implications [3].

Regarding the management of emphysematous pyelonephritis, different authors have described patient benefit from adequate fluid resuscitation, electrolyte management, strict glycemic control, and broad-spectrum antibiotic administration. In the correlation of emphysematous pyelonephritis and diabetic ketoacidosis, it is important to take therapeutic actions to both infection and metabolic decompensation. This is accomplished with low insulin doses administered by continuous pump infusion as well as fluid therapy; antibiotic treatment should be modified culture results are available [6]. Satisfactory results have been reported with conservative medical treatment or medical treatment combined with percutaneous drainage in cases of localized emphysematous pyelonephritis (HUANG 1 or 2) [2,6].

Here we present a case report of emphysematous pyelonephritis with concomitant diabetic ketoacidosis.

Case Presentation

First case

A 37-year-old type 2 poorly controlled diabetic woman with a history of multiple UTIs was admitted to Emergency Department. Upon admission, the patient referred two-week history of malaise with intermittent fever accompanied by poliaquiuria, followed by abdominal and lumbar pain. Initial evaluation revealed tachycardia, tachypnea, hypotension, signs of dehydration, and generalized abdominal pain with extension to the lumbar region, in addition to a positive bilateral Giordano´s sign. Studies revealed leukocytosis plus neutrophilia, hyperglycemia, hyperazoemia and a decompensated high anion gap metabolic acidosis, meeting criteria for moderate DKA. Initial urinalysis reported positive leucose esterase, bacteria, glycosuria and ketonuria; which pointed out a possible infection site, renal sonography revealed acute bilateral pyelonephritis. Initial management included intravenous fluids, empirical antibiotic therapy and insulin infusion. Despite this, abdominal pain and hyperglycemia persisted. Urine culture reported ESBL E. coli and antibiotic therapy was switched, we conducted an abdominal CT scan revealed emphysematous pyelonephritis Huang 2 and emphysematous cystitis (Figure 1A) and performed specific medical treatment. After 14 days, we performed a new abdominal CT scan with resolution of both emphysematous infections, DKA and was discharged home (Figure 1B).

Citation:Buenrostro-Valenzuela JC, Amezquita-Perez J, Schlie-Villa W and Romero-Bermudez J. Diabetic Ketoacidosis Triggered by an Emphysematous Urinary Tract Infection: A Case Report and Mini-Review of Literature. J Fam Med. 2021; 8(5): 1259.