Emphysematous pyelonephritis

Background

• Rare gas-forming infection nearly always occurring in pts w/ DM and obstruction
  • Pts appear toxic and septic; nephrectomy may be required

Clinical Features

• Fever
• Abdominal pain or Flank pain
  • crepitus over the flank may be present in severe cases
• Nausea/vomiting
• Dyspnea
• Renal dysfunction
• Altered mental status
• Shock
• Thrombocytopenia

Differential Diagnosis

Dysuria

• Genitourinary infection
  • Acute cystitis ("UTI")
  • Pyelonephritis
  • Urethritis
  • Chronic cystitis
  • Infected nephrolithiasis
  • Prostatitis
  • Epididymitis
  • Renal abscess/perinephric abscess
  • Emphysematous pyelonephritis
• Nephrolithiasis
• Urethral issue
  • Urethritis
  • Urolithiasis
  • Urethral foreign body
  • Urethral diverticulum
  • Allergic reaction (contact dermatitis)
  • Chemical irritation
  • Urethral stricture or obstruction
  • Trauma to vagina, urethra, or bladder
• Gynecologic
  • Vaginitis/cervicitis
  • PID
  • Genital herpes
  • Pelvic organ prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • Interstitial cystitis
  • Behavioral symptom without detectable pathology

Diagnosis

Labs

• CBC with high WBC, low platelets
• UA with urine culture
• Creatinine
• Blood culture

Imaging

• CT is definitive

Management

• IVF
• Antibiotics
  • IV ampicillin, gentamicin, metronidazole
  • Vancomycin in place of ampicillin for pcn allergy

Disposition

• Urological c/s for surgical drainage, stent placement, or nephrectomy
• Presence of obstructive stone requires even more urgent surgical intervention
• Mortality rates between ~20-40%
• Poor prognostic factors:
  • Cr > 1.4 mg/dL
  • Platelets < 60k