Emphysematous Pyelonephritis In A Diabetic Patient With Remarkable Radiological Findings And Excellent Outcome Without Surgical Intervention Or Drainage

Objective: Rare diseaseBackground: Emphysematous pyelonephritis (EPN) is a life-threatening infection of the renal parenchyma. The purpose of this report is to present a case of EPN with distinctive imaging.Case Report: An 87-year-old man with a history of type 2 diabetes mellitus presented to the ER with fever and shivering, hypotension, and anuria, which is a clinical presentation of septic shock. He had recently been hospitalized at another hospital due to myocardial infarction and ischemic stroke, where a temporary urinary catheter was placed. Upon physical examination, he had right lateral abdominal pain with extension to the right renal region. Laboratory studies showed leucocytosis (WBC: 24 320/mu l with 94.4% polymorphonuclear), elevated C-reactive protein 340 mg/l (NV <3.45), and acute renal failure (urea 155mg/dl NV <50 mg/dl, creatinine 4.4 mg/dl NV <1.2 mg/dl). A plain X-ray showed air was present peripheral to the right kidney, while the abdominal CT revealed air inside the right kidney and bilateral nephrolithiasis. The patient was initially put on a ressive hydration, vasoconstrictors, and hydrocortisone to treat the septic shock, and an advanced antibiotic treatment (meropenem) was initiated immediately. Blood culture grew Escherichia ca. After 3 days of treatment, he showed significant improvement in diuresis and renal function (urea 90 mg/dl, creatinine 1.0 mg/dl), with a concomitant decrease in inflammatory markers (CRP 36.7 mg/l). The antibiotic treatment was tapered to cefuroxime and metronidazole. The patient's condition improved, and he was discharged with per os antibiotic treatment. Subsequently, surgical assessment for the nephrolithiasis was suggested.Conclusions: Emphysematous pyelonephritis, although rare, should be included in the differential diagnosis of fever in a diabetic patient with renal pain.