A Rare Case of Emphysematous Pyelonephritis

Background: This case illustrates the potential for class 3A emphysematous pyelonephritis with the presence of nephrolithiasis to be initially treated solely by relieving the hindered urinary outflow and with systemic antibiotics if diagnosed early with appropriate imaging studies. Case Presentation: 64-year-old Caucasian female with history of diabetes mellitus type 2, hyperlipidemia, hypertension, coronary artery disease and diastolic congestive heart failure presented to the emergency department with respiratory distress of 2 days duration. Her chief complaint was associated with anuria for two days, abdominal pain, generalized weakness, and loss of appetite. The patient was admitted to the medical intensive care unit (MICU) for hypotension, severe mixed respiratory and metabolic acidosis, and uremia. She was intubated for pending respiratory failure and underwent emergency hemodialysis for acute renal failure. She received hemodynamic support and was also started on systemic antibiotics. A computerized tomography (CT) scan of the abdomen/pelvis revealed class 3A emphysematous pyelonephritis (EPN) of the left kidney and an 8 mm nonobstructing calculus in the left proximal ureter. Subsequently a left ureteral stent was placed to relieve the obstruction. In addition, blood cultures revealed bacteremia with Klebsiella pneumoniae. Although she had thrombocytopenia, acute renal failure and shock, the intra-renal emphysema improved with the stent and she was eventually weaned off of vasopressors, extubated and showed marked clinical improvement. Conclusion: Rare cases of class 3A EPN precipitated by any degree of urinary tract obstruction may be treated initially with relief of outflow hindrance and aggressive supportive care if an early diagnosis can be made with appropriate imaging studies.