Images in emergency medicine

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Diagnosis 

Emphysematous pyelonephritis. She had an atrophic left kidney and an enlarged right kidney with emphysematous pyelonephritis.

Emphysematous pyelonephritis is a rare, severe, gas-forming infection of renal parenchyma and its surrounding areas that occurs almost exclusively in patients with diabetes mellitus.¹ Acute renal infection with Escherichia coli or Klebsiella pneumoniae instigates the development of emphysematous pyelonephritis, and a mixed acid fermentation by Enterobacteriaceae is what leads to gas formation. Clinical findings of sepsis or complicated urinary tract infection in a diabetic patient warrant an abdominal imaging because of the life-threatening potential. Management depends on the extent of parenchymal destruction per radiographic studies and includes percutaneous drainage with antibiotics treatment or nephrectomy.

In our patient, a percutaneous drainage demonstrated pyelosanguinous fluid, and the organism was identified as E coli. Nephrectomy and renal stenting have been discussed as treatment options; the family has refused surgical intervention.

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Reference 

1. Huang J, Tseng C. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160:797–805
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