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Emphysematous Pyelonephritis Caused by Candida tropicalis

      To the Editor:
      Emphysematous pyelonephritis is a severe necrotizing infection characterized by gas formation within the renal parenchyma, collecting system, and perinephric tissues.
      • Pontin A.R.
      • Barnes R.D.
      • Joffe J.
      • Kahn D.
      Emphysematous pyelonephritis in diabetic patients.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      • Shokeir A.A.
      • El-Azab M.
      • Mohsen T.
      • El-Diasty T.
      Emphysematous pyelonephritis: a 15-year experience with 20 cases.
      This condition commonly occurs in women with diabetes mellitus and obstructive uropathy.
      • Pontin A.R.
      • Barnes R.D.
      • Joffe J.
      • Kahn D.
      Emphysematous pyelonephritis in diabetic patients.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      • Shokeir A.A.
      • El-Azab M.
      • Mohsen T.
      • El-Diasty T.
      Emphysematous pyelonephritis: a 15-year experience with 20 cases.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      • Wan Y.L.
      • Lee T.Y.
      • Bullard M.J.
      • Tsai C.C.
      Acute gas-producing bacterial renal infection: correlation between imaging findings and clinic outcome.
      Escherichia coli and Klebsiella are the most common organisms cultured.
      • Pontin A.R.
      • Barnes R.D.
      • Joffe J.
      • Kahn D.
      Emphysematous pyelonephritis in diabetic patients.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      • Shokeir A.A.
      • El-Azab M.
      • Mohsen T.
      • El-Diasty T.
      Emphysematous pyelonephritis: a 15-year experience with 20 cases.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      • Wan Y.L.
      • Lee T.Y.
      • Bullard M.J.
      • Tsai C.C.
      Acute gas-producing bacterial renal infection: correlation between imaging findings and clinic outcome.
      Rarely, Candida species have been reported to cause emphysematous pyelonephritis.
      • Hildebrand T.S.
      • Nibble L.
      • Frei U.
      • Schindler R.
      Bilateral emphysematous pyelonephritis caused by Candida infection.

      Case Report

      A 51-year-old African-American transgender male with history of intravenous drug abuse presented to the emergency department with nausea, vomiting, and oliguria for 10 days. She had severe abdominal pain in the right upper quadrant and generalized weakness. She denied fever, dysuria, and flank pain.
      On examination, she appeared lethargic. She was afebrile, with a heart rate of 114 beats per minute and blood pressure of 206/110 mm Hg. Abdominal examination revealed tenderness to palpation in the right flank and costovertebral angle. Otherwise, the examination was unremarkable.
      Laboratory results showed leukocytosis of 19,800/mm3, hemoglobin of 12.5 g/dL, and platelet count of 292,000/mm3. Sodium was 119 mmol/L, potassium 7.4 mmol/L, chloride 83 mmol/L, bicarbonate 17 mmol/L, blood urea nitrogen 130 mg/dL, creatinine 10.57 mg/dL, and blood glucose 494 mg/dL. An abdominal computed tomography (CT) scan showed edema and perinephric stranding involving the right kidney, and air within the right renal collecting system (Figure).
      Figure thumbnail gr1
      FigureComputerized tomography of abdomen showing gas collection in the right renal pelvis.
      Antegrade pyelogram showed obstruction in the right renal pelvis by a fungal ball. A percutaneous nephrostomy catheter was placed and fluid cultures grew Candida tropicalis. The patient was managed conservatively with intravenous Amphotericin B and hemodialysis. During the hospital course, she was diagnosed with diabetes mellitus and her hemoglobin A1C was 16.8%. Subsequent imaging studies showed that the fungal ball had disintegrated. Her clinical condition and renal function gradually improved.

      Discussion

      In 1962, Schultz and Klorfein
      • Schultz E.H.
      • Klorfein E.H.
      Emphysematous pyelonephritis.
      first used the term emphysematous pyelonephritis to describe an acute infectious process resulting in gas formation in the renal parenchyma. It has been postulated that various factors, including mixed acid fermentation by gas-forming bacteria, high tissue glucose concentrations, impaired immunity, and tissue ischemia, contribute to the gas formation.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      Emphysematous pyelonephritis usually presents with fever, flank pain, and pyuria.
      • Pontin A.R.
      • Barnes R.D.
      • Joffe J.
      • Kahn D.
      Emphysematous pyelonephritis in diabetic patients.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      • Shokeir A.A.
      • El-Azab M.
      • Mohsen T.
      • El-Diasty T.
      Emphysematous pyelonephritis: a 15-year experience with 20 cases.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      The presentation also could include thrombocytopenia, acute renal failure, altered mental status, and shock.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      Rarely, emphysematous pyelonephritis could be the presenting feature of diabetes mellitus, as in our patient.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      Also, our patient is the first reported case of a transgender male with emphysematous pyelonephritis.
      CT scan is the most accurate method of diagnosing emphysematous pyelonephritis.
      • Pontin A.R.
      • Barnes R.D.
      • Joffe J.
      • Kahn D.
      Emphysematous pyelonephritis in diabetic patients.
      • Ahlering T.E.
      • Boyd S.D.
      • Hamilton C.L.
      • et al.
      Emphysematous pyelonephritis: a 5-year experience with 13 patients.
      • Shokeir A.A.
      • El-Azab M.
      • Mohsen T.
      • El-Diasty T.
      Emphysematous pyelonephritis: a 15-year experience with 20 cases.
      Wan et al
      • Wan Y.L.
      • Lee T.Y.
      • Bullard M.J.
      • Tsai C.C.
      Acute gas-producing bacterial renal infection: correlation between imaging findings and clinic outcome.
      described 2 types based on CT findings. Type I is characterized by parenchymal destruction with streaky or mottled gas, but no fluid collection. Type II is characterized by renal or perirenal fluid collection with bubbly or loculated gas or gas in the collecting system. Type I has a higher mortality rate (69%) than Type II (18%).
      • Wan Y.L.
      • Lee T.Y.
      • Bullard M.J.
      • Tsai C.C.
      Acute gas-producing bacterial renal infection: correlation between imaging findings and clinic outcome.
      Our patient's presentation was consistent with Type II emphysematous pyelonephritis.
      Treatment often consists of a combination of medical therapy and percutaneous drainage.
      • Huang J.
      • Tseng C.
      Emphysematous pyelonephritis.
      Urological consultation is prudent, as nephrectomy may be required for severe or resistant cases.

      Acknowledgements

      We thank Ms. Bonnie Mastel, Library Technician Specialist at Legacy Emanuel Hospital and Dr. Mark Crislip, Infectious Diseases Specialist at Legacy Good Samaritan Hospital, Portland, Oregon for their support in preparing this manuscript.

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