Emphysematous pyelonephritis treated with percutaneous catheter drainage and antibiotics

A 58-year-old woman presented acutely with a 3-day history of general weakness, vomiting and fever. For 2 years she had had untreated diabetes mellitus. On examination she was ill, blood pressure was 64/47mmHg, heart rate: 111 beats/min, respiration rate: 28/min and body temperature was 37.28C. The right upper abdomen was tender. There was right loin tenderness. Investigations: white blood cell count 10 380/mm; haemoglobin 7.8 g/dl; haematocrit 23.1%; platelet count 36 000/mm; blood urea nitrogen 70mg/dl; serum creatinine 6.2mg/dl; glucose 302mg/dl; C-reactive protein 21.4mg/dl; sodium 129mEq/l; potassium 4.1mEq/l; chloride 98mEq/l; and total CO2 8.9mEq/l. An arterial blood gas pH 7.242, pO2 60mmHg, pCO2 22mmHg and bicarbonate 9.3mEq/l. A plain abdominal film showed air density in the right pelvocalyceal system and upper ureter (Figure 1). Computed tomography (CT) of the abdomen without contrast confirmed the presence of air in the pelvicalyceal system and upper ureter of the enlarged right kidney (Figure 2). Six hours after admission, she became hypotensive and unconscious. She was intubated and ventilated. She received fluid resuscitation, emergency haemodialysis, and intravenous piperacillin and tazobactam. A percutaneous catheter was inserted into the pelvicalyceal system of the right kidney and drained turbid fluid. Blood and urine cultures grew Escherichia coli. The catheter was removed on day 12 because of disappearance of air in right excretory system at follow-up CT. Antibiotic therapy was continued for 4 weeks. She survived but did not recover renal function.