Emphysematous pyelonephritis
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Emphysematous pyelonephritis (EPN) is a morbid infection of kidneys, with characteristic gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and carries a high mortality.
Clinical presentation
Flank pain, urinary tract obstruction with fever. Leukocytosis and hyperglycemia (in diabetics) are prominent lab findings. Thrombocytopenia is particularly associated with poor prognosis 3.
Pathology
Aetiology
It tends to be commoner more common in females. Approximately 90% of patients have uncontrolled diabetes1. It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms or sloughing of papilla.
Causative organisms include
-
E. Coli
-: usually considered the commonest causative organism 3 - Klebsiella pneumonia
- Proteus mirabilis
Radiographic features
Plain film and fluoroscopy (IVP)
May show mottled gas within renal fossa or crescentic gas collection within Gerota's fascia. Linear gas shadows along paraspinal region may also be seen, representing retroperitoneal air.
Ultrasound
- may show an enlarged kidney with coarse echoes within renal parenchyma or collecting system.
- dirty echogenic foci with reverberation
/ ring/ring-downartefactsartifacts representing air ('dirty shadowing') may also be seen.
Bowel gas over kidneys may lead to false positive diagnosis.
CT
CT is the best diagnostic modality for emphysematous pyelonephritis. It may show following diagnostic features
- enlarged, destructed renal parenchyma
- small bubbly or linear streaks of gas1
- fluid collections, with gas-fluid levels
- focal necrotic areas +/- abscess
Radiological classification
CT features of emphysematous pyelonephritis differentiates into two types:
-
type 1
-- renal parenchymal destruction with streaky or mottled appearance of gas
. - intra- or extrarenal fluid collections are characteristically absent
. - it is usually more aggressive and lead to death shortly, if not intervened early
.
- renal parenchymal destruction with streaky or mottled appearance of gas
-
type 2
--
renal or extrarenal collections associated with bubbly or loculated gas, or gas within pelvicalyceal system or ureter
.
-
renal or extrarenal collections associated with bubbly or loculated gas, or gas within pelvicalyceal system or ureter
In addition to this, the Huang-Tseng CT classification system 4 is also described which is as:
-
class 1
-:gasgas in collecting system only -
class 2:
- gasgas in renal parenchyma only (without extrarenal extension) -
class 3
-
class 3a:
- extensionextension of gas or abscess to perinephric space -
class 3b:
- extensionextension of gas or abscess to pararenal space
-
class 3a:
-
class 4:
- bilateralbilateral emphysematous pyelonephritis or solitary kidney with emphysematous pyelonephritis
Treatment and prognosis
In mild cases, intravenous antibiotics are administered and percutaneous catheter drainage of perirenal or retroperitoneal collections is done. Severe cases often warrantswarrant a nephrectomy.
Differential diagnosis
General imaging differential considerations include
- emphysematous pyelitis
- iatrogenic (instrumentation, or intervention of urinary tract)
- ureter-ileosigmoidostomy or fistulous communication with bowel.
See also
-<p><strong>Emphysematous pyelonephritis (EPN)</strong> is a morbid infection of kidneys, with characteristic gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and carries a high mortality.</p><h4>Clinical presentation</h4><p>Flank pain, urinary tract obstruction with fever. Leukocytosis and hyperglycemia (in diabetics) are prominent lab findings. Thrombocytopenia is particularly associated with poor prognosis <sup>3</sup>.</p><h4>Pathology</h4><h5>Aetiology</h5><p>It tends to be commoner in females. Approximately 90% of patients have uncontrolled diabetes<sup>1</sup> . It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms or sloughing of papilla.</p><p>Causative organisms include</p><ul>- +<p><strong>Emphysematous pyelonephritis (EPN)</strong> is a morbid infection of kidneys, with characteristic gas formation within or around the <a href="/articles/kidneys">kidneys</a>. If not treated early, it may lead to fulminant sepsis and carries a high mortality.</p><h4>Clinical presentation</h4><p>Flank pain, urinary tract obstruction with fever. Leukocytosis and hyperglycemia (in diabetics) are prominent lab findings. Thrombocytopenia is particularly associated with poor prognosis <sup>3</sup>.</p><h4>Pathology</h4><h5>Aetiology</h5><p>It tends to be more common in females. Approximately 90% of patients have uncontrolled diabetes <sup>1</sup>. It may however also be seen in immunocompromised individuals or associated with <a href="/articles/urolithiasis">urolithiasis</a>, neoplasms or sloughing of papilla.</p><p>Causative organisms include</p><ul>
-<em>E. Coli</em> - usually considered the commonest causative organism <sup>3</sup>- +<em>E. Coli</em>: usually considered the commonest causative organism <sup>3</sup>
-<li>dirty echogenic foci with reverberation / ring-down artefacts representing air ('dirty shadowing') may also be seen.</li>- +<li>dirty echogenic foci with <a href="/articles/reverberation-artifact">reverberation</a>/ring-down artifacts representing air ('dirty shadowing') may also be seen</li>
-<li>small bubbly or linear streaks of gas<sup>1</sup>- +<li>small bubbly or linear streaks of gas <sup>1</sup>
-<li>focal necrotic areas + / - abscess</li>-</ul><h4>Radiological classification</h4><p>CT features of emphysematous pyelonephritis differentiates into two types</p><ul>- +<li>focal necrotic areas +/- <a href="/articles/renal-abscess">abscess</a>
- +</li>
- +</ul><h4>Radiological classification</h4><p>CT features of emphysematous pyelonephritis differentiates into two types:</p><ul>
-<strong>type 1</strong> -<ul>-<li>renal parenchymal destruction with streaky or mottled appearance of gas.</li>-<li>intra- or extrarenal fluid collections are characteristically absent.</li>-<li>it is usually more aggressive and lead to death shortly, if not intervened early.</li>- +<strong>type 1</strong><ul>
- +<li>renal parenchymal destruction with streaky or mottled appearance of gas</li>
- +<li>intra- or extrarenal fluid collections are characteristically absent</li>
- +<li>it is usually more aggressive and lead to death shortly, if not intervened early</li>
-<strong>type 2</strong> - renal or extrarenal collections associated with bubbly or loculated gas, or gas within pelvicalyceal system or ureter.</li>-</ul><p>In addition to this, the <strong>Huang-Tseng CT classification system</strong> <sup>4</sup> is also described which is as</p><ul>- +<strong>type 2</strong><ul><li>
- +<strong></strong>renal or extrarenal collections associated with bubbly or loculated gas, or gas within pelvicalyceal system or <a href="/articles/ureter">ureter</a>
- +</li></ul>
- +</li>
- +</ul><p>In addition to this, the <strong>Huang-Tseng CT classification system</strong> <sup>4</sup> is also described: </p><ul>
-<strong>class 1 -</strong> gas in collecting system only</li>- +<strong>class 1:</strong> gas in collecting system only</li>
-<strong>class 2</strong> - gas in renal parenchyma only (without extrarenal extension)</li>- +<strong>class 2:</strong> gas in renal parenchyma only (without extrarenal extension)</li>
-<strong>class 3a</strong> - extension of gas or abscess to perinephric space</li>- +<strong>class 3a:</strong> extension of gas or abscess to perinephric space</li>
-<strong>class 3b</strong> - extension of gas or abscess to pararenal space</li>- +<strong>class 3b:</strong> extension of gas or abscess to pararenal space</li>
-<strong>class 4</strong> - bilateral emphysematous pyelonephritis or solitary kidney with emphysematous pyelonephritis</li>-</ul><h4>Treatment and prognosis</h4><p>In mild cases, intravenous antibiotics are administered and percutaneous catheter drainage of perirenal or retroperitoneal collections is done. Severe cases often warrants a nephrectomy.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include</p><ul>- +<strong>class 4:</strong> bilateral emphysematous pyelonephritis or solitary kidney with emphysematous pyelonephritis</li>
- +</ul><h4>Treatment and prognosis</h4><p>In mild cases, intravenous antibiotics are administered and percutaneous catheter drainage of perirenal or retroperitoneal collections is done. Severe cases often warrant a nephrectomy.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include</p><ul>
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Case 7 -: left kidney
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