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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).
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.
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.
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%).
Urological consultation is prudent, as nephrectomy may be required for severe or resistant cases.
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.
Emphysematous pyelonephritis in diabetic patients.
Conflict of Interest: The authors do not have any conflicts of interest to disclose.
Authorship: Both authors had access to data and a role in preparing the manuscript. Prasanna V. Krishnasamy was on Nephrology rotation and Christopher Liby was on Medicine rotation when they saw this patient together at Good Samaritan Hospital and Medical Center, Portland, Oregon.