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UROLOGICAL IMAGE |
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| Year : 2022 | Volume
: 38
| Issue : 4 | Page : 315-316 |
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A rare neurological presentation of emphysematous pyelonephritis
S Lal Darsan, Biju S Pillai, H Krishnamoorthy
Department of Urology, Lourdes Hospital Post Graduate Institute of Medical Science and Research, Kochi, Kerala, India
| Date of Submission | 09-May-2022 |
| Date of Decision | 13-Jun-2022 |
| Date of Acceptance | 18-Jun-2022 |
| Date of Web Publication | 1-Oct-2022 |
Correspondence Address:
S Lal Darsan
Department of Urology, Lourdes Hospital Post Graduate Institute of Medical Science and Research, Kochi, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/iju.iju_145_22
 Abstract | | |
Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the kidney with features of air formation in the pelvicalyceal system, renal parenchyma, and surrounding structures. Although septic embolization has been reported to occur in distant organs, air pockets occurring intracranially leading to neurological manifestations in EPN have not been reported in the literature. We present a case report of a patient with EPN showing air pockets in renal parenchyma, pelvicalyceal system, renal vein, inferior vena cava, and multiple intracranial venous sinuses, presenting predominantly with neurological symptoms. This patient was aggressively managed with antibiotics, ureteral stenting, and drainage of the right kidney.
How to cite this article:
Darsan S L, Pillai BS, Krishnamoorthy H. A rare neurological presentation of emphysematous pyelonephritis. Indian J Urol 2022;38:315-6 |
| Introduction | |  |
Emphysematous pyelonephritis (EPN) is a potentially fatal, acute necrotizing infection of the kidney caused by gas-forming bacteria with air formation in the pelvicalyceal system and renal parenchyma. Unusually, EPN has been reported to cause pneumomediastinum, subcutaneous emphysema, and septic emboli in some distant organs.[1] We present a very rare case report of EPN presenting with predominant neurological symptoms due to air pockets in the superior sagittal sinus and bilateral cavernous sinuses.
| Case Report | | |
A 58-year-old male patient presented to the urology outpatient department (OPD) with a 2-day history of right-sided flank pain. He had been previously treated for kidney stones. He had altered sensorium, slurring of speech, swaying to one side on walking, and giddiness at presentation. On examination, he had elevated temperature, tachycardia, and hypotension. Investigations revealed evidence of septicemia with leukocytosis, elevated serum C-reactive protein (169 mg/dL), elevated blood sugar levels (350 mg/dL), and serum creatinine (4.6 mg/dL). Urine microscopy showed pyuria. Noncontrast computed tomography (CT) of the abdomen showed EPN of the right kidney with extensive air pockets in perinephric tissue, renal parenchyma, pelvicalyceal system, renal vein, and inferior vena cava (IVC) [Figure 1]. CT imaging of the brain revealed air pockets inside the superior sagittal sinus and bilateral cavernous sinuses [Figure 2]. A pulmonary CT was not done due to normal oxygen saturation, normal ECG, and absence of chest signs. Screening of the lower lungs during CT abdomen revealed normal lower lung fields. The patient was managed with crystalloids, inotropic support, intravenous antibiotics, and insulin. Hemodialysis was done and systemic acidosis was corrected. Urine and blood cultures were positive for Escherichia coli. Open right renal abscess drainage with ureteral stenting was done on day 3. Sepsis was controlled in another 48 h and the neurological status returned to normal with no sequelae. | Figure 1: CT abdomen, (a): Air in perinephric space, renal parenchyma, and renal pelvis (yellow arrows), (b): Air embolism inside inferior vena cava (green arrow). CT: Computed tomography
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 | Figure 2: CT brain. (a): Various projections show air embolism in superior sagittal sinus (yellow arrows) and bilateral cavernous sinuses (green arrow), (b): Sagittal section shows air embolism in cavernous sinus (green arrow). CT: Computed tomography
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| Discussion | | |
EPN is a rare and potentially fatal complication of upper urinary tract infection in the presence of uncontrolled diabetes mellitus caused by gas-forming bacteria including E. coli, Klebsiella and Proteus. High levels of tissue glucose provide a substrate for uropathogens, which produce carbon dioxide by the fermentation of sugar. The gas bubbles can enter the bloodstream and embolize to various organs including the lungs and coronary artery by spreading through the renal vein, IVC, right heart, and pulmonary circulation.[2] EPN presenting with renal vein and IVC thrombus has been reported to occur in newly detected diabetes mellitus.[3] Chang et al. reported very rare cases of hepatic portal venous gas occurring in hemodialytic women with EPN.[4] The diagnosis, extent, and severity of disease are established by radiological investigations including CT scan. Aggressive treatment of the condition includes crystalloid resuscitation, strict control of glucose, electrolyte and acid–base management, broad-spectrum antibiotic therapy, percutaneous nephrostomy or stenting to relieve ureteral obstruction, and occasionally nephrectomy in patients with extensive renal damage.[5]
Our patient had air pockets in the right renal pelvicalyceal system, parenchyma, perirenal tissue, renal vein, and IVC. CT scan of the brain revealed air pockets also in superior sagittal and bilateral cavernous sinuses which accounted for his neurological symptoms. The exact mechanism of embolization of air to the intracranial venous circulation could not be explained. We hypothesize that the air bolus traveled up the continuous venous blood column through IVC to the right atria, superior vena cava, right internal jugular vein and then to the dural sinuses due to the upright position the patient maintained on a wheelchair while reaching the hospital and during OPD consulting, rather than the air being diverted to pulmonary circulation by the right atrium to the right ventricle route. EPN causing embolization of air into dural venous sinuses has not been reported in the literature.
| Conclusion | | |
EPN presenting with neurological manifestations have to be investigated and managed promptly to avoid permanent neurological complications.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
| References | | |
| 1. | Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol 2004;11:909-11.  |
| 2. | Razazi K, Luciani A, de Prost N, Mekontso Dessap A. Multiple gas emboli complicating an emphysematous pyelonephritis. IDCases 2018;12:64-5. |
| 3. | Jeyaraman R, Karunamoorthy R, Marzook SA. Emphysematous pyelonephritis with IVC thrombus in new onset diabetes mellitus. Indian J Urol 2013;29:348-50. [ PUBMED] [Full text] |
| 4. | Chang CJ, Shun HC, Chuang CC. Hepatic portal venous gas induced by emphysematous pyelonephritis: A rare case in hemodialytic women. Am J Emerg Med 2009;27:1171.e1-3. |
| 5. | Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805. |
[Figure 1], [Figure 2]
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