Emphysematous pyelonephritis: An unusual case of pneumoperitoneum and intra-abdominal wall abscess

Praveen S Padasali; K Kshirsagar; VS Shankaregowda; BR Prakash

doi:10.4103/2320-3846.147033

Users Online: 1485

CASE REPORT

Year : 2014 | Volume : 2 | Issue : 3 | Page : 99-102

Emphysematous pyelonephritis: An unusual case of pneumoperitoneum and intra-abdominal wall abscess

Praveen S Padasali, K Kshirsagar, VS Shankaregowda, BR Prakash
Department of Surgery, Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

Date of Web Publication

15-Dec-2014

Correspondence Address:
Praveen S Padasali
S/O - S G Padasali, Maitri Galli, Jamkhandi, D-Bagalkot, Karnataka - 587 301
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/2320-3846.147033

Abstract

Emphysematous pyelonephritis (EPN) is a rare gas-producing life-threatening necrotizing bacterial infection that involves the renal parenchyma and the perirenal tissue. It is encountered primarily in patients with diabetes mellitus or ureteral obstruction associated with perinephric and intrarenal gas. Causative organisms are those normally found in the urinary and gastrointestinal tracts. Multiple gas-producing organisms were the cause of the free intraperitoneal and perinephric air however anaerobic bacteria have been demonstrated in only 1% of cases. We describe a case of EPN, which presented as an acute abdomen with pneumoperitoneum in a diabetic patient. On the exploration, no visceral pathology was found, but the patient had right intra-abdominal wall abscess. Subsequent exploration revealed right pyelonephritis. Thus, presenting an unusual presentation of EPN as pneumoperitoneum and intra-abdominal wall abscess.

Keywords: Emphysematous, intra-abdominal wall abscess, pneumoperitoneum

How to cite this article:
Padasali PS, Kshirsagar K, Shankaregowda V S, Prakash B R. Emphysematous pyelonephritis: An unusual case of pneumoperitoneum and intra-abdominal wall abscess . Saudi Surg J 2014;2:99-102

How to cite this URL:
Padasali PS, Kshirsagar K, Shankaregowda V S, Prakash B R. Emphysematous pyelonephritis: An unusual case of pneumoperitoneum and intra-abdominal wall abscess . Saudi Surg J [serial online] 2014 [cited 2023 May 28];2:99-102. Available from: https://www.saudisurgj.org/text.asp?2014/2/3/99/147033

Introduction

Emphysematous pyelonephritis (EPN) is a severe, potentially fatal, necrotizing pyelonephritis with a variable clinical picture ranging from mild abdominal pain to septic shock. The majority of cases occur in diabetics with poor glycemic control whereas a small percentage may be due to urinary tract obstruction. ^[1],[2]

The first case of gas-forming renal infection was reported in 1898 by Kelly and MacCallum. ^[3] Since then many names have been used to describe EPN such as renal emphysema, pyelonephritis emphysematous and pneumonephritis. ^[4] In 1962, Schultz and Klorfein proposed EPN as the preferred designation name, because it stresses the relationship between acute renal infection and gas formation. ^[5]

Earlier researches proposed that a vigorous resuscitation and appropriate medical treatment should be followed by immediate nephrectomy. ^[2],[6] However, recent surgical advances in treatment, allow patients to be treated with percutaneous drainage in combination with broad spectrum antibiotics. ^[1],[7],[8] We present an unusual case of pneumoperitoneum and abdominal wall abscess due to EPN in a patient with medical history of diabetes that was successfully treated with antibiotics and open drainage.

Case Report

A 58-year-old male with medical history of diabetes presented to the emergency department with a 3 days history of dull aching pain abdomen, vomiting and abdomen distension. On clinical examination, after admission revealed an ill-appearing man, confused and agitated. His vital signs showed a temperature of 41°C, pulse rate 92 beats/min and blood pressure of 140/90 mm Hg and respiratory rate of 24/min. On per abdomen examination abdominal distension present, diffuse tenderness present, and liver dullness was obliterated. He had been anuric for 24 h prior to admission and after catheterization of his urinary bladder collected 600 ml of urine.

Laboratory tests revealed a white blood cell count (WBC) count of 11,100/mm ³ with 76% granulocytes, hemoglobin of 9.3 g/dl, platelet count of 173,010/mm ³ , liver function test-normal, creatinine level of 1.8 mg/dl and urea of 100 mg/dl. Urine analysis demonstrated numerous WBC, gram-negative bacteria present. Erect X-ray of the abdomenshows air under right dome of the diaphragm [Figure 1]. Computed tomography Computed tomography (CT) Scan examination of the abdomen shows free gas was in the intra-peritoneal and in the extra-peritoneal space, as well free abdominal fluid around 1.5 l with septations [Figure 2] and [Figure 3]. The extra-peritoneal collected gas was located mostly in the right perinephric area with multiple air pockets and collection in right perinephric area and in the anterior abdominal wall [Figure 4].

Figure 1: Right pyelonephritis with air under diaphragm

Click here to view

Figure 2: Cross section showing whole length of right kidney with pyelonephritis

Click here to view

Figure 3: Cross section of right pyelonephritis with intra-abdominal wall abscess

Click here to view

Figure 4: Sagittal plane showing right pyelonephritis

Click here to view

Abdomen exploration done in midline around 2 l of pus drained. The hollow viscus organs examined from stomach to sigmoid, no pathology noted. The intra-abdominal wall abscess located in the right lumbar region, walled by peritoneum and abdominal muscles extending medially up to lateral border of rectus identified and around 250 ml of pus drained. The right colon mobilized, and the abscess in the right nephric area was found and treated with drainage. Thorough abdominal lavage given, drain kept and abdomen closed in midline. The patient was treated with intravenous Meropenem 1 g/day bed-days for 14 days. Pus Cultures showed the offensive microorganism to be Escherichia ^{More Details} coli. On postoperative day 6 due to draining blockage, CT scan done for follow up and noted collection in the right perinephric area. Ultrasound guided percutaneous drainage of right perinephric area done. The patient had an uneventful postoperative course later, and his symptoms resolved completely.

Discussion

Emphysematous pyelonephritis has been defined as a necrotizing infection of the renal parenchyma and its surrounding areas that result in the presence of gas in the renal parenchyma, collecting system or perinephric tissue. ^[1] More than 90% of cases occur in diabetics with poor glycemic control. Other predisposing factors include urinary tract obstruction, polycystic kidneys, end stage renal disease and immunosuppression. ^[1],[2]

The pathogenesis of EPN remains unclear however four factors have been implicated, including gas-forming bacteria, high tissue glucose level (favoring rapid bacterial growth), impaired tissue perfusion (diabetic nephropathy leads to further compromise regional oxygen delivery in the kidney resulting in tissue ischemia and necrosis; nitrogen released during tissue necrosis) and a defective immune response due to impaired vascular supply. Intrarenal thrombi and renal infarctions have been claimed to be predisposing factors in non-diabetic patients. ^[1],[2]

The main bacteria causing EPN are the classical germs of urinary tract infection. The most common is E. coli. Other bacteria include Klebsiella pneumoniae, Proteus mirabilis and Pseudomonas aeruginosa. ^{[1],[2],[3],[4],[5],[6],[7]} Anaerobic infection is extremely uncommon. ^[9]

The mean patient age is 55-years-old. Women outnumbered men probably due to their increased susceptibility to urinary tract infections. The left kidney was more frequently involved than the right one. ^[1] The clinical manifestations of EPN appear to be similar to those encountered in classical cases of upper urinary tract infections. According to Huang and Tseng ^[4] fever was encountered in 79% of the patients, abdominal or back pain in 71%, nausea and vomiting in 17%, lethargy and confusion in 19%, dyspnea in 13% and shock in 29%. Laboratory testing revealed elevated glycosylated hemoglobin in 72%, leukocytosis in 67%, thrombocytopenia in 46% and pyuria in 79%. This data comes to an agreement with those generally reported in the literature. ^{[2],[6],[7],[8],[9],[10],[11],[12]}

Various imaging techniques can be used to detect gas within the genitourinary system. Ultrasound is insensitive for the diagnosis of renal gas but useful in diagnosing urinary tract obstruction. It is also a readily available, non-invasive method that is quite useful in the hands of experienced practitioners. ^[11] Non-contrast CT scan remains the diagnostic method of choice. In addition to showing the presence of gas, it defines the extent of the infection and can diagnose any obstruction. ^[1],[2]

The treatment of EPN remains controversial. According to some investigators ^[5],[6] vigorous resuscitation, administration of antimicrobial agents and control of blood glucose and electrolytes should be followed by immediate nephrectomy. Huang and Tseng et al. ^[4],[8] proposed certain therapeutic modalities based upon their radiological classification system. Localized EPN (class 1 and 2) is confronted by antibiotic treatment, combined with CT-guided percutaneous drainage. For extensive EPN (classes 3 and 4) without signs of organ dysfunction antibiotic therapy combined with percutaneous catheter placement should be attempted. However, nephrectomy should be promptly attempted in patients with extensive EPN and signs of organ dysfunction.

Conclusion

In summary, this patient presented with pneumoperitoneum, which is a rare presentation. The unusual thing was, it also presented with intra-abdominal wall abscess, which is not reported anywhere. Probably, the mechanism is by creeping of retroperitoneal abscess along peritoneum and collected in the right lumbar region medially up to the lateral border of rectus sheath.

This patient had diabetes with EPN with intra-abdominal wall abscess, which can be better treated by open drainage and antibiotics. Percutaneous drainage or open drainage, along with antibiotic treatment, may be a reasonable alternative to nephrectomy. However, surgical intervention should not be delayed in patients with extensive disease extending to the abdominal wall.

References

1.	Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.
2.	Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: A 15-year experience with 20 cases. Urology 1997;49:343-6.
3.	Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol 1984;131:203-8.
4.	Schultz EH Jr, Klorfein EH. Emphysematous pyelonephritis. J Urol 1962;87:762-6.
5.	Huang Kelly HA, MacCallum WG. Pneumaturia. JAMA 1898;31:375-81.
6.	Ahlering TE, Boyd SD, Hamilton CL, Bragin SD, Chandrasoma PT, Lieskovsky G, et al. Emphysematous pyelonephritis: A 5-year experience with 13 patients. J Urol 1985;134:1086-8.
7.	Wang JM, Lim HK, Pang KK. Emphysematous pyelonephritis. Scand J Urol Nephrol 2007;41:223-9.
8.	Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ. Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis 2005;46:432-9.
9.	Christensen J, Bistrup C. Case report: Emphysematous pyelonephritis caused by clostridium septicum and complicated by a mycotic aneurysm. Br J Radiol 1993;66:842-3.
10.	Vetere NS, Monti J, Gutman D. A case report of emphysematous pyelonephritis secondary to ureteral obstruction in a non-diabetic patient. Am J Emerg Med 2006;24:749-50.
11.	Stone SC, Mallon WK, Childs JM, Docherty SD. Emphysematous pyelonephritis: Clues to rapid diagnosis in the Emergency Department. J Emerg Med 2005;28:315-9.
12.	Mallet M, Knockaert DC, Oyen RH, Van Poppel HP. Emphysematous pyelonephritis: No longer a surgical disease? Eur J Emerg Med 2002;9:266-9.