Emphysematous
pyelonephritis is a severe, life-threatening
infection of the renal parenchyma and perinephric tissues. This condition is primarily encountered in patients with
diabetes mellitus or
ureteral obstruction, and is characterized by the production of intrarenal and perinephric gas. Emphysematous
pyelonephritis is associated with a high degree of morbidity and a high mortality rate.
CASE PRESENTATION: A 72-year-old woman with a history of
diabetes mellitus,
hypertension, and
renal calculi was referred to our emergency department following 6 days of
abdominal pain. She suddenly developed
pain in the entire abdomen, and was transferred. Physical examination was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm(3), platelet count of 17,000/mm(3),
creatinine level of 1.64 mg/dl, and serum
glucose level of 603 mg/dl. Abdominal computed tomography indicated the presence of free air in the intraperitoneal cavity and right perirenal space,
hydronephrosis of the right kidney, and stones in the right distal ureter. After 1 hour, the vital signs changed and she appeared to become drowsy. Therefore, the patient was transferred to the operation room for
laparotomy. On exploration of the abdomen, 1.5 L of
pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue
necrosis and a perforation site were identified at the superior border of the right kidney. Thus, emphysematous
pyelonephritis was diagnosed and she underwent right radical
nephrectomy. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Follow-up CT performed after 10 days showed fluid collection and
hematoma at the
nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up computed tomography after 3 weeks indicated that the fluid collection at the
nephrectomy site had nearly disappeared.
CONCLUSIONS: We believe that cases with free intraperitoneal air should promptly undergo
laparotomy to identify the cause of the
pneumoperitoneum. Moreover, an immediate
nephrectomy may be effective for the treatment of emphysematous
pyelonephritis in cases with poor prognostic factors.