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URO RADIOLOGY |
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| Year : 2005 | Volume
: 21
| Issue : 2 | Page : 118-119 |
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Emphysematous pyelonephritis
A Karthikeyan, S Kumar, G Ganesh
Department of Urology, Christian Medical College, Vellore, Tamilnadu, India
Correspondence Address:
G Ganesh
Department of Urology, Christian Medical College,Vellore - 632 004,Tamilnadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.19635
How to cite this article:
Karthikeyan A, Kumar S, Ganesh G. Emphysematous pyelonephritis. Indian J Urol 2005;21:118-9 |
Kelly and Mac Callum reported the first case of emphysematous pyelonephritis (EPN) in 1898. Emphysematous pyelonephritis is a rare life threatening necrotising infection of the renal parenchyma and perirenal tissue. By strict definition EPN should be applied to the disease characterized by gas formation in the renal parenchyma and its surrounding structures. The predisposing factors are diabetes mellitus and ureteric obstruction. Escherichia More Details coli and Klebsiella pneumoniae are the most common organisms isolated from urine culture. The diagnosis of EPN is established radiologically. Emphysematous pyelonephritis is classified into types 1 and 2.[1] A much simpler classification is class 1: gas confined to collecting system; class 2: gas confined to renal parenchyma [Figure - 1]; class 3a: extension of gas to perinephric space; class 3b: extension of gas to pararenal space [Figure - 2]; class 4: bilateral or solitary kidney with EPN.[2]
Emphysematous pyelonephritis should be suspected in every diabetic patient presenting with acute pyelonephritis. Ultrasound should be done as a screening investigation and if there is hyper echoic focus within the kidney a non-contrast abdominal computed tomographic (CT) scan (CT) is recommended. Computed tomographic CT scan accurately defines the extent of gas and rules out the other differential diagnosis for hyper echoic focus within the kidney. We do not recommend a contrast CT due to compromised renal reserve and moreover a functional assessment is not required in the presence of active infection.
Thrombocytopenia, shock, altered sensorium and acute renal function impairment are considered as poor prognostic factors. Management of EPN has evolved from aggressive surgical intervention to conservative management. Antibiotic treatment alone is not recommended. Conservative treatment with parentral antibiotics and percutaneous drainage is recommended as the first line treatment.[2],[3] In the absence of symptomatic improvement a repeat CT scan is performed at our center to assess the adequacy of drainage and if necessary a second percutaneous drainage tube is placed. If the above measures fail or if there is worsening of the general condition an emergency nephrectomy is recommended. A nuclear scan is mandatory in those managed conservatively after 3-4 weeks of antibiotics. An elective nephrectomy is indicated if the kidney is nonfunctioning. Measures to preserve the kidney in these patients should be considered due to their compromised renal function and the risk of recurrence in the contralateral kidney.
 References | |  |
| 1. | Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996;198:433-8.  [PUBMED] |
| 2. | Huang JJ, Tseng CC. Emphysematous pyelonephritis. Arch Intern Med 2000;160:797-805. [PUBMED] [FULLTEXT] |
| 3. | Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: 15 years experience with 20 cases. Urology. 1997;49:343-6. |
[Figure - 1], [Figure - 2]
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