Clinical profile, management and outcomes of class IV emphysematous pyelonephritis in a tertiary care center: A retrospective descriptive study

Class IV Emphysematous pyelonephritis (EPN) is a life-threatening infection of the kidney, and there is sparse data on immediate and long-term outcomes of medical management. The study aimed to review the clinical presentation, diagnosis, immediate and long-term outcomes of medical management, and outcome of patients presenting with class IV EPN Methods. This retrospective study was conducted in a tertiary care center in Dharwad, India. The study included class IV EPN patients admitted to the hospital between Jan 2012 to Dec 2019. The factors studied were demographics, comorbidities, radiological investigations, clinical presentation, urine, blood and pus culture, and sensitivity and treatment history. Immediate and long-term outcomes of medical management were determined. Descriptive analysis of the data was conducted. Continuous variables were presented as mean ± standard deviation and discrete variables in terms of number (%). Results. Twenty-one patients with class IV EPN, with a mean age of 55.7 ±13.5 years, were analyzed. The majority were males (M: F 15:6). The patients were followed up for 32.70±21.12 months. Fever, flank or abdominal pain, and acute kidney injury were observed in all 21 patients, while nausea and/or vomiting and dysuria were seen in 16 (76.2%) patients. E. Coli was the most common pathogen found. Double J stenting was done in 20 (95.2%) patients; Ultrasonography guided aspiration 8(38.1%) and percutaneous drainage in 5 (23.8%) patients. One (4.8%) patient died during the first episode and 3(19%) others due to recurrent infection and end-stage renal disease. Conclusions. Class IV Emphysematous pyelonephritis can be managed successfully by minimally invasive modalities. However, long-term morbidity and mortality risks are still negative.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

<b><i>Introduction:</i></b> The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN). <b><i>Methods:</i></b> We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm³ were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality. <b><i>Results:</i></b> Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm³ and lower PLR ≤18.4 increased the risk of drainage failure (<i>p</i> = 0.009 and 0.001, respectively). <b><i>Conclusion:</i></b> Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

Case Report: Emphysematous Pyelonephritis With a Congenital Giant Ureterocele

A 14-year-old girl noticed malodorous urine and experienced left flank pain. The patient was presented to our hospital with gradually increasing pain. She had no underlying disease but had a history of pain on micturition for several days. Hematologic examination indicated low white blood cell and platelet counts and a high serum lactate level. Computed tomography showed that a part of the parenchyma of the left kidney had poor contrast and was deteriorated, with fluid and gas retention from the perirenal region to the retroperitoneal cavity. A left hydroureter and large ureterocele were observed in the bladder. She was diagnosed with emphysematous pyelonephritis (EPN) with a giant congenital ureterocele. Vasopressors and blood transfusion failed to maintain normal circulatory dynamics, and an open left nephrectomy and transurethral ureterocele fenestration were performed. The excised outer portion of the left kidney was dissolved by the infection and replaced with blood clots and necrotic tissue. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identified the inflammatory, gas-producing bacteria Actinotignum schaalii, Peptoniphilus asaccharolyticus, and Actinomyces odontolyticus. Meropenem was administered for 4 days postoperatively and then de-escalated to sulbactam/ampicillin for another 10 days. The patient was discharged on day 17 of hospitalization, and the postoperative course remained favorable. EPN is extremely rare in pediatric patients, and it is believed that nephrectomy is sometimes necessary if the patient does not have normal circulatory dynamics despite the use of catecholamines.

Coexistence of Emphysematous Pyelonephritis and Cystitis in a Patient with COVID-19 Complicated with Spontaneous Pneumomediastinum

We report the first case of a 52-year-old nondiabetic male admitted for management of uremic syndrome associated with emphysematous pyelonephritis (EPN), renal and perinephric abscess, and emphysematous cystitis (EC) on a single functional kidney with a large abundance of spontaneous pneumomediastinum (SP) complicating a SARS-CoV-2 pneumonia. The patient has benefited from several dialysis sessions, intravenous antibiotics, and percutaneous drainage. His clinical course was complicated by acute respiratory distress syndrome, and unfortunately, he died nine days following admission.